Factors associated with timeliness of post-primary care referral, diagnosis and treatment for lung cancer: population-based, data-linkage study

Where are the inequalities in ovarian cancer care in a country with universal healthcare? A systematic review and narrative synthesis

INTRODUCTION

Patients diagnosed with ovarian cancer from more deprived areas may face barriers to accessing timely, quality healthcare. We evaluated the literature for any association between socioeconomic group, treatments received and hospital delay among patients diagnosed with ovarian cancer in the United Kingdom, a country with universal healthcare.

METHODS

We searched MEDLINE, EMBASE, CINAHL, CENTRAL, SCIE, AMED, PsycINFO and HMIC from inception to January 2023. Forward and backward citation searches were conducted. Two reviewers independently reviewed titles, abstracts, and full-text articles. UK-based studies were included if they reported socioeconomic measures and an association with either treatments received or hospital delay. The inclusion of studies from one country ensured greater comparability. Risk of bias was assessed using the QUIPS tool, and a narrative synthesis was conducted. The review is reported to PRISMA 2020 and registered with PROSPERO [CRD42022332071].

RESULTS

Out of 2876 references screened, ten were included. Eight studies evaluated treatments received, and two evaluated hospital delays. We consistently observed socioeconomic inequalities in the likelihood of surgery (range of odds ratios 0.24-0.99) and chemotherapy (range of odds ratios 0.70-0.99) among patients from the most, compared with the least, deprived areas. There were no associations between socioeconomic groups and hospital delay.

POLICY SUMMARY

Ovarian cancer treatments differed between socioeconomic groups despite the availability of universal healthcare. Further research is needed to understand why, though suggested reasons include patient choice, health literacy, and financial and employment factors. Qualitative research would provide a rich understanding of the complex factors that drive these inequalities.

What can patient-reported experience measures tell us about the variation in patients' experience of prostate cancer care? A cross-sectional study using survey data from the National Prostate Cancer Audit in England

OBJECTIVES

A national survey aimed to measure how men with prostate cancer perceived their involvement in and decisions around their care immediately after diagnosis. This study aimed to describe any differences found by socio-demographic groups.

DESIGN

Cross-sectional study of men who were diagnosed with and treated for prostate cancer.

SETTING

The National Prostate Cancer Audit patient-reported experience measures (PREMs) survey in England.

PARTICIPANTS

Men diagnosed in 2014-2016, with non-metastatic prostate cancer, were surveyed. Responses from 32 796 men were individually linked to records from a national clinical audit and to administrative hospital data. Age, ethnicity, deprivation and disease risk classification were used to explore variation in responses to selected questions.

PRIMARY AND SECONDARY OUTCOME MEASURES

Responses to five questions from the PREMs survey: the proportion responding to the highest positive category was compared across the socio-demographic characteristics above.

RESULTS

When adjusted for other factors, older men were less likely than men under the age of 60 to feel side effects had been explained in a way they could understand (men 80+: relative risk (RR)=0.92, 95% CI 0.84 to 1.00), that their views were considered (RR=0.79, 95% CI 0.73 to 0.87) or that they were involved in decisions (RR=0.92, 95% CI 0.85 to 1.00). The latter was also apparent for men who were not white (black men: RR=0.89, 95% CI 0.82 to 0.98; Asian men: RR=0.85, 95% CI 0.75 to 0.96) and, to a lesser extent, for more deprived men.

CONCLUSIONS

The observed discrepancies highlight the need for more focus on initiatives to improve the experience of ethnic minority patients and those older than 60 years. The findings also argue for further validation of discriminatory instruments to help cancer care providers fully understand the variation in the experience of their patients.

Rethinking the logic of early diagnosis in cancer

To reduce morbidity and mortality of cancer, more countries have implemented strategies to detect cancer, based on the logic of 'the sooner the better'. Time is thereby an essential component in how cancer research, policies, and prevention are practiced today. Where the logic of early diagnosis benefits some, the logic also produces harms. In this article, we use a cross-disciplinary case-study design to discuss how different notions of time and linearity are essential in today's research ontology of cancer, describe the individual and societal consequences of such ontology, and invite a rethinking of time in cancer. Drawing on theoretical concepts of time together with cancer epidemiological, historical and ethnographical data, we analyse how the logic of early diagnosis has been established as a stable concept. Although evidence supporting the logic points in different directions, the message 'the sooner the better' is currently not being challenged by research, policy or society. This at least partly, can be explained by a linear perception of time and societal traces of neoliberalism and acceleration in our society together with cancer still being a somewhat enigmatic disease that requires acute action. To support a sustainable healthcare sector, we argue there is a need to nuance the logic of early diagnosis. Continuing the linear perception of symptoms and cancer, risks doing more harm than good by making more people patients unnecessarily and by spending health resources on those with the least need.

Evaluating the Optimal Time Between Diagnosis and Surgical Intervention for Early-Stage Lung Cancer

INTRODUCTION

There is no consensus on the optimal timing for lung cancer surgery. We aim to evaluate the impact of timing of surgical intervention. We hypothesize delay in intervention is associated with worse overall survival and higher pathologic upstaging in early-stage lung cancer.

METHODS

We identified patients with cT1/2N0M0 nonsmall cell lung cancer in the National Cancer Database from 2004 to 2018. Patients were categorized by time to surgery groups: early (<26 d), average (26-60 d), and delayed (61-365 d). Primary outcome was overall survival and secondary outcome was pathologic upstaging. Multivariate models and survival analyses were used to determine factors associated with time from diagnosis to surgery, pathologic upstaging, and overall survival.

RESULTS

In multivariate model, advanced age, non-Hispanic Black patients, nonprivate insurance, low median income and education, and treatment at low-volume facilities were less likely to undergo early intervention and compared to the average group were more likely to receive delayed intervention. Pathologic upstaging was more likely in the delayed group (odds ratio 1.11, 1.07-1.14) compared to early group (odds ratio 0.96, 0.93-0.99). Early intervention was associated with improved overall survival (hazard ratio 0.93, 0.91-0.95), while delayed intervention was associated with inferior survival (hazard ratio 1.11, 1.09-1.14).

CONCLUSIONS

Expeditious surgical intervention is associated with lower rates of pathologic upstaging and improved overall survival in early-stage lung cancer. Delays in surgery are associated with social and economic factors, suggesting disparities in access to surgery. Lung cancer surgery should be performed as quickly as possible to maximize oncologic outcomes.

Machine Learning Techniques to Predict Timeliness of Care among Lung Cancer Patients

Delays in the assessment, management, and treatment of lung cancer patients may adversely impact prognosis and survival. This study is the first to use machine learning techniques to predict the quality and timeliness of care among lung cancer patients, utilising data from the Victorian Lung Cancer Registry (VLCR) between 2011 and 2022, in Victoria, Australia. Predictor variables included demographic, clinical, hospital, and geographical socio-economic indices. Machine learning methods such as random forests, k-nearest neighbour, neural networks, and support vector machines were implemented and evaluated using 20% out-of-sample cross validations via the area under the curve (AUC). Optimal model parameters were selected based on 10-fold cross validation. There were 11,602 patients included in the analysis. Evaluated quality indicators included, primarily, overall proportion achieving "time from referral date to diagnosis date ≤ 28 days" and proportion achieving "time from diagnosis date to first treatment date (any intent) ≤ 14 days". Results showed that the support vector machine learning methods performed well, followed by nearest neighbour, based on out-of-sample AUCs of 0.89 (in-sample = 0.99) and 0.85 (in-sample = 0.99) for the first indicator, respectively. These models can be implemented in the registry databases to help healthcare workers identify patients who may not meet these indicators prospectively and enable timely interventions.

Ageism directed to older adults in health services: A scoping review

OBJECTIVE

to map the expressions of ageism directed to older adults in health services and the respective coping measures.

METHOD

a scoping review of primary studies in English, Spanish and Portuguese, without time delimitation and collected from 14 databases. Selection of the titles, abstracts and full text was in charge of two independent and blinded reviewers, totaling a corpus comprised by 41 articles. Data extraction was performed by pairs. The data were presented in narrative summaries and charts.

RESULTS

the ageism expressions are understood at the interpersonal level through images and attitudes that depreciate, devalue life and delegitimize older adults' needs, as well as at the institutional level, which confers barriers to accessing health services, generating non-assistance and neglect. The coping measures consist of educational interventions and expansion of communication channels between aged people, health professionals and managers.

CONCLUSION

the results may make health professionals vigilant for care/neglect guided by age bias and sensitive for coping with ageism by obtaining diverse scientific knowledge. The analysis of the phenomenon in the Unified Health System context constitutes a knowledge gap, as well as the implicit ageism expressions. (1) Ageism expressions involve interpersonal and institutional relationships. (2) Ageism directed to older adults permeates from diagnosis to treatment. (3) The coping measures comprise educational actions and also scientific research studies. (4) It is necessary to recognize the presence of ageism in health services. (5) It is necessary to recognize care/neglect practices guided by age bias.

Ageism directed to older adults in health services: A scoping review

OBJECTIVE

to map the expressions of ageism directed to older adults in health services and the respective coping measures.

METHOD

a scoping review of primary studies in English, Spanish and Portuguese, without time delimitation and collected from 14 databases. Selection of the titles, abstracts and full text was in charge of two independent and blinded reviewers, totaling a corpus comprised by 41 articles. Data extraction was performed by pairs. The data were presented in narrative summaries and charts.

RESULTS

the ageism expressions are understood at the interpersonal level through images and attitudes that depreciate, devalue life and delegitimize older adults' needs, as well as at the institutional level, which confers barriers to accessing health services, generating non-assistance and neglect. The coping measures consist of educational interventions and expansion of communication channels between aged people, health professionals and managers.

CONCLUSION

the results may make health professionals vigilant for care/neglect guided by age bias and sensitive for coping with ageism by obtaining diverse scientific knowledge. The analysis of the phenomenon in the Unified Health System context constitutes a knowledge gap, as well as the implicit ageism expressions. (1) Ageism expressions involve interpersonal and institutional relationships. (2) Ageism directed to older adults permeates from diagnosis to treatment. (3) The coping measures comprise educational actions and also scientific research studies. (4) It is necessary to recognize the presence of ageism in health services. (5) It is necessary to recognize care/neglect practices guided by age bias.

Managing the cancer backlog: a national population-based study of patient mobility, waiting times and 'spare capacity' for cancer surgery

Background

Waiting times for cancer treatments continue to increase in many countries. In this study we estimated potential 'spare surgical capacity' in the English NHS and identified regions more likely to have spare capacity based on patterns of patient mobility (the extent to which patients receive surgery at hospitals other than their nearest).

Methods

We identified patients who had an elective breast or colorectal cancer surgical resection between January 2016 and December 2018. We estimated each hospital's 'maximum surgical capacity' as the maximum 6-month moving average of its surgical volume. 'Spare surgical capacity' was estimated as the difference between maximum surgical capacity and observed surgical volume. We assessed the association between spare surgical capacity and whether a hospital performed more or fewer procedures than expected due to patient mobility as well as the association between spare surgical capacity and whether or not waiting times targets for treatment were likely to be met.

Findings

100,585 and 49,445 patients underwent breast and colorectal cancer surgery respectively. 67 of 166 hospitals (40.4%) providing breast cancer surgery and 82 of 163 hospitals (50.3%) providing colorectal cancer surgery used less than 80% of their maximum surgical capacity. Hospitals with a 'net loss' of patients to hospitals further away had more potential spare capacity than hospitals with a 'net gain' of patients (p < 0.001 for breast and p = 0.01 for colorectal cancer). At the national level, we projected an annual potential spare capacity of 8389 breast cancer and 4262 colorectal cancer surgical procedures, approximately 25% of the volumes actually performed.

Interpretation

Spare surgical capacity potentially exists in the present configuration of hospitals providing cancer surgery and requires regional allocation for efficient utilisation.

Funding

National Institute for Health Research.

The Effect of Timeliness of Care on Lung Cancer Survival - A Population-Based Approach

Background

Timeliness of care is an important dimension of healthcare quality but it's unclear whether it improves clinical outcomes in lung cancer (LC) patients.

Objectives

This study aims to analyze treatment patterns, time-to-treatment (TTT) and the impact of treatment timeliness (TT) in overall survival (OS) of patients diagnosed with LC in 2009-2014 in a population-based registry from Southern Portugal.

Materials and Methods

We estimated median TTT for overall population, treatment type and stage. The impact of treatment and TT on five-year OS was analyzed using the Kaplan-Meier method and Cox regression modelling to determine the hazard ratio (HR) of death associated with treatment and TT.

Results

From the 11,308 cases diagnosed, 61.7% received treatment. Treatment rate decreased with increasing stage from 88% in stage I to 66.1% in stage IV. Overall median TTT was 49 days (IQR: 28-88) and 43.3% received TT. Surgery had a longer TTT than radiotherapy and systemic treatment. Patients in earlier stages had lower TT rates and longer TTT compared to more advanced, 24.7% and 80 days in stage I versus 51.3% and 42 days in stage IV (p < 0.0001). OS was 14.9% for total population and 19.6% and 7.1% for patients with and without treatment registered, respectively. TT had no observed impact on OS for stages I/II but a negative effect for stages III/IV. Relative to treated, the adjusted mortality risk was higher in untreated patients (HR = 2.240; 95%CI: 2.293-2.553). Contrary to treatment, TT had a negative impact on survival, with 11.3% in timely vs. 21.5% in untimely treated. Compared to untimely treated, the risk of death in TT patients was 46.6% higher (HR = 1.465; 95%CI: 1.381-1.555).

Conclusions

LC survival is highly dependent on early diagnosis and adequate treatment. Time-to-treatment was longer than recommended for all treatment types but particularly for surgery. Overall TT results were paradoxical, as better survival was observed in patients untimely treated. The factors associated with TT were not possible to analyze and its impact on patient outcomes remains unclear. However, it is important to assess quality-of-care to improved LC management.

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.

Association between socioeconomic status and net survival after primary lung cancer surgery: a tertiary university hospital retrospective observational study in Japan

BACKGROUND

Inequalities in opportunities for primary lung cancer surgery due to socioeconomic status exist. We investigated whether socioeconomic inequalities exist in net survival after curative intent surgery at a tertiary university hospital, in Japan.

METHODS

Data from the hospital-based cancer registry on primary lung cancer patients who received lung resection between 2010 and 2018 were linked to the surgical dataset. An area deprivation index, calculated from small area statistics and ranked into tertiles based on Japan-wide distribution, was linked with the patient's address as a proxy measure for individual socioeconomic status. We estimated net survival of up to 5 years by deprivation tertiles. Socioeconomic inequalities in cancer survival were analyzed using an excess hazard model.

RESULTS

Of the 1039 patient-sample, advanced stage (Stage IIIA+) was more prevalent in the most deprived group (28.1%) than the least deprived group (18.0%). The 5-year net survival rates (95% confidence interval) from the least to the most deprived tertiles were 82.1% (76.2-86.6), 77.6% (70.8-83.0) and 71.4% (62.7-78.4), respectively. The sex- and age-adjusted excess hazard ratio of 5-year death was significantly higher in the most deprived group than the least deprived (excess hazard ratio = 1.64, 95% confidence interval: 1.09-2.47). The hazard ratio reduced toward null after additionally accounting for disease stage, suggesting that the advanced stage may explain the poor prognosis among the deprived group.

CONCLUSION

There was socioeconomic inequality in the net survival of patients who received curative intent surgery for primary lung cancer. The lower socioeconomic status group might be less likely to receive early curative surgery.

Characterizing Regional Variability in Lung Cancer Outcomes across Ontario-A Population-Based Analysis

Background: Lung cancer (LC) is the leading cause of cancer-related mortality. In Ontario, Canada, there are significant survival differences for patients with newly diagnosed LC across the 14 provincial regions. Methods: A population-based retrospective cohort study using ICES databases from 01/2007-12/2017 identified patients with newly diagnosed LC through the Ontario Cancer Registry and those with LC as the cause of death. Descriptive data included patient, disease, and system characteristics. The primary outcome was 5-year survival by region. Results: 178,202 patient records were identified; 101,263 met inclusion criteria. LC incidence varied by region (5.6-14.6/10,000), as did histologic subtype (adenocarcinoma: 27.3-46.1%). Five-year cancer-specific survival was impacted by age, rurality, pathologic subtype, stage at diagnosis, and income quintile. Timely care was inversely related to survival (fastest quintile: HR 3.22, p < 0.0001). Adjusted 5-year cancer-specific survival varied across regions (24.1%, HR 1.12; 34.0%, HR 0.89, p < 0.001). Conclusions: When adjusting for confounders, differences in survival by health region persisted, suggesting a complex interplay between patient, disease, and system factors. A single approach to improving patient care is likely to be ineffective across different systems. Quality improvement initiatives to improve patient outcomes require different approaches amongst health regions to address local disparities in care.

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.

Wait Times and Survival in Lung Cancer Patients across the Province of Quebec, Canada

Lung cancer is the leading cause of cancer death worldwide, with a five-year survival of 22% in Canada. Guidelines recommend rapid evaluation of patients with suspected lung cancer, but the impact on survival remains unclear. We reviewed medical records of all patients with newly diagnosed lung cancer in four hospital networks across the province of Quebec, Canada, between 1 February and 30 April 2017. Patients were followed for 3 years. Wait times for diagnosis and treatment were collected, and survival analysis using a Cox regression model was conducted. We included 1309 patients, of whom 39% had stage IV non-small cell lung cancer (NSCLC). Median wait times were, in general, significantly shorter in patients with stage III–IV NSCLC or SCLC. Surgery was associated with delays compared to other types of treatments. Median survival was 12.9 (11.1–15.7) months. The multivariate survival model included age, female sex, performance status, histology and stage, treatment, and the time interval between diagnosis and treatment. Longer wait times had a slightly protective to neutral effect on survival, but this was not significant in the stage I–II NSCLC subgroup. Wait times for the diagnosis and treatment of lung cancer were generally within targets. The shorter wait times observed for advanced NSCLC and SCLC might indicate a tendency for clinicians to act quicker on sicker patients. This study did not demonstrate the detrimental effect of longer wait times on survival.

Pattern of Treatment Initiation and Outcomes for Patients With Metastatic Non-small Cell Lung Cancer in Ontario

Introduction: The impact of diagnosis and treatment delay on outcomes in advanced non-small cell lung carcinoma (NSCLC) is not well understood. In this study, we examined the effect of the length of time to the first chemotherapy treatment initiation and the other factors affecting overall survival.

Methods: This retrospective study used data from the Institute of Clinical Evaluative Sciences and identified 4520 patients in Ontario who were diagnosed with stage IV NSCLC between 2007 and 2016, treated using chemotherapy. We adjusted the analysis for location (rural vs urban), gender, distance from the nearest cancer center, first chemotherapy treatment used, income, and age. 

Results: Type of the chemotherapy, length of time to the first treatment, and distance from the nearest cancer center had a statistically significant impact on survival. Paclitaxel was associated with decreased risk of death compared to vinorelbine (Hazard Ratio (HR)=0.835, 95%CI 0.753-0.925), gemcitabine (HR=0.916, 95%CI 0.998-0.826), and docetaxel (HR=0.771, 95%CI 0.994-0.513). Every additional 10 km distance from the nearest cancer center was associated with a 0.5% increased risk of death (HR=1.005, 95%CI 1.000-1.010). A longer time to the first treatment was associated with increased survival. In fact, every 10 days increase in wait time was associated with a 0.5% decrease in the risk of death (HR=0.995, 95%CI 0.993-0.998). 

Conclusion: Chemotherapy treatment using paclitaxel and living closer to the cancer center is associated with better survival. A longer time between diagnosis and treatment leading to better survival could perhaps be explained by patients on the "sicker" end of the spectrum receiving treatment sooner.

Defining timeliness in care for patients with lung cancer: a scoping review

OBJECTIVES

Early diagnosis and reducing the time taken to achieve each step of lung cancer care is essential. This scoping review aimed to examine time points and intervals used to measure timeliness and to critically assess how they are defined by existing studies of the care seeking pathway for lung cancer.

METHODS

This scoping review was guided by the methodological framework for scoping reviews by Arksey and O'Malley. MEDLINE, EMBASE, CINAHL and PsycINFO electronic databases were searched for articles published between 1999 and 2019. After duplicate removal, all publications went through title and abstract screening followed by full text review and inclusion of articles in the review against the selection criteria. A narrative synthesis describes the time points, intervals and measurement guidelines used by the included articles.

RESULTS

A total of 2113 articles were identified from the initial search. Finally, 68 articles were included for data charting process. Eight time points and 14 intervals were identified as the most common events researched by the articles. Eighteen different lung cancer care guidelines were used to benchmark intervals in the included articles; all were developed in Western countries. The British Thoracic Society guideline was the most frequently used guideline (20%). Western guidelines were used by the studies in Asian countries despite differences in the health system structure.

CONCLUSION

This review identified substantial variations in definitions of some of the intervals used to describe timeliness of care for lung cancer. The differences in healthcare delivery systems of Asian and Western countries, and between high-income countries and low-income-middle-income countries may suggest different sets of time points and intervals need to be developed.

Diagnosing pancreatic cancer in general practice: a cross-sectional study on associations between suspicion of cancer, urgent referral and time to diagnosis

OBJECTIVE

This study aimed to investigate the first point of contact in patients diagnosed with pancreatic cancer, and to study factors associated with the GP's suspicion of cancer, Cancer Patient Pathway (CPP) referral and long diagnostic interval.

DESIGN

Cross-sectional study combining register and survey data.

PATIENTS

Patients with incident pancreatic cancer recorded in the Danish National Patient Register (n = 303).

MAIN OUTCOME MEASURES

The patient's first point of symptoms presentation, GP's cancer suspicion, CPP referral and diagnostic interval.

RESULTS

General practice was the first point of contact for 85.5% of the population. At the first consultation, cancer was suspected in 32.7% and 22.9% were referred to a CPP. The GPs were more likely to suspect cancer or serious illness in patients aged >70 years (prevalence rate ratio (PRR) 1.34, 95% CI 1.09-1.66) and among patients with high comorbidity (PRR 1.23, 95% CI 1.04-1.47). A CPP referral was less likely among patients with low education. The median diagnostic interval was 39 days (interquartile range: 15-72). When the GP initially did not suspect cancer, the likelihood of longer diagnostic interval increased.

CONCLUSION

The majority of patients with pancreatic cancer began their diagnostic route in general practice. Diagnosing pancreatic cancer swiftly in general practice was challenging; the GP did often not initially suspect cancer or refer to a CPP and several of the patient characteristics were associated with the GPs initial suspicion of cancer or CPP referral. Thus, there may be room for improvements in the diagnostics of pancreatic cancer in general practice.Key pointsPatients with pancreatic cancer have a poor prognosis, as pancreatic cancer is often diagnosed in late stage.The majority of patients with pancreatic cancer began their diagnostic process in general practice.General practitioners (GPs) suspected cancer at the first consultation in one out of three patients with pancreatic cancer; more often in older and comorbid patients.The GPs suspicion of cancer was associated with urgent referral and shorter time to diagnosis.

Factors associated with time to initiate lung cancer treatment in Minas Gerais, Brazil

The aim was to verify the association of individual factors and healthcare system characteristics with time to initiate treatment of lung cancer by the Brazilian National Health System, in Minas Gerais state. A retrospective cohort study, with patients who initiated treatment for lung cancer by the SUS, from 2008 to 2015. Sociodemographic and clinical characteristics of patients, besides organizational variables of the healthcare system were selected. The logistic regression model evaluated the association of selected explanatory variables with the outcome of initiating treatment within 60 days after diagnosis. Odds ratio (OR) and respective 95% confidence interval were used to measure the power of association. Most treatments for lung cancer in the state of Minas Gerais initiated within 60 days after diagnosis. However, being male and diagnosed as stage IV increased the likelihood of starting treatment within 60 days. On the other hand, the patient's age, radiation therapy as first treatment, and the place of residence decreased such chance. Time to initiate treatment is associated with individual characteristics and provision of services in macroregions, and the observed inequalities possibly raised from the better or worse access of the population to the services provided by SUS.

Delays in Diagnosis and Treatment in Patients Underwent Endobronchial Ultrasound-Transbronchial Needle Aspiration (EBUS-TBNA)

OBJECTIVES

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has been recognized as the first method of choice in the diagnosis of mediastinal and hilar lesions. Although the procedure is commonly used, there is no study assessing its contribution to the duration required for diagnosis and treatment. In this study, we aimed to determine the extent of diagnosis and treatment delays when using the EBUS-TBNA procedure and to address the possible factors contributing to these delays.

MATERIALS AND METHODS

The demographic data, pathological diagnosis, need for additional procedures, symptoms, presenting complaints, and the time until the beginning of treatment were recorded retrospectively in all patients who had undergone EBUS-TBNA.

RESULTS

A total of 134 patients (mean age 60.7 ± 12 years, M/F: 78/56) were included. Delay of the patients was found in 60.4% (n = 81), delayed referral in 35.8% (n = 48), diagnosis delays in 84.3% (n = 113), treatment delays in 38.8% (n = 52), and total delay in 73.1% (n = 98) of the patients. A statistically significant association was found between referral delay and total delay with age groups (p=0.006) and between patient delay and the presence of symptoms (p=0.027). EBUS-TBNA was found to have the lowest effect among all delay parameters (β: 0.104, p < 0.001) in the regression analysis. When diagnosis times' subgroups were compared, EBUS-TBNA was found to have the least effect (correlation coefficient: 0.134, p=0.004).

CONCLUSION

We found that approximately ¾ of the patients had a delay and this is not acceptable in real terms. Considering that the patient burden is increasing day by day, it is necessary to make a radical change in health care or a change in strategy in order to prevent delays. EBUS-TBNA, which is in the diagnosis delay subgroup, is less invasive and accelerates the process.

"One stop" clinic for upper gastrointestinal cancer-an alternative to "straight to test" referrals?

BACKGROUND

Patients suspected to have upper gastrointestinal (UGI) cancer can be referred directly for investigation; however, at times this may result to inappropriate referrals. This study explores the model of a "one-stop" clinic as an alternative to the direct referral system. The current study aims to assess the feasibility and outcomes of a one-stop UGI clinic and evaluate sensitivity and specificity of "on-the-day" diagnoses.

METHODS

A retrospective analysis of case notes of patients seen in one-stop clinic, between January 2017 and January 2019, was conducted. All General Practitioner (GP) referrals were screened by a specialist nurse.

RESULTS

After completion of the post-GP referral screening process, 252 patients (median age 68 years, IQR 58.8-77.3 years; M:F ratio 118:134) were allocated to the one-stop clinic. OGD was not required, contra-indicated or declined in 27 cases (10.7%). The records of three patients could not be found. One patient did not attend. Overall, 221 patients underwent testing and received "on-the-day" diagnoses. Sensitivity was 94% (range 87-100%), and specificity was 92% (88-96%). Ninety-six percent of patients received a diagnosis on the day.

CONCLUSIONS

The one-stop clinic was feasible and had good specificity and sensitivity. The finding of 10.7% of cases not being suitable for OGD indicates that a patient/specialist consultation is necessary to prevent misuse of endoscopy appointments. The authors recommend widespread adoption of one-stop clinics in UGI surgery.

Associations Between Time to Treatment Start and Survival in Patients With Lung Cancer

BACKGROUND

Time-to-treatment is defined as a quality indicator for cancer care but is not well documented. We investigated whether meeting Norwegian timeframes of 35/42 days from referral until start of chemotherapy or surgery/radiotherapy for lung cancer was associated with survival.

PATIENTS AND METHODS

The medical records of 439 lung cancer patients at a regional cancer center were reviewed and categorized according to treatment: (i) surgery; ii) radical radiotherapy; iii) stereotactic radiotherapy; iv) palliative treatment, no cancer symptoms; v) palliative treatment with severe cancer symptoms).

RESULTS

Proportions receiving timely treatment varied significantly at 39%, 48%, 10%, 44% and 89%, respectively (p<0.001). Overall, those starting treatment on time had the shortest median overall survival (10.6 vs. 22.6 months; p<0.001). This was also the case for palliative (5.3 vs. 11.4 months) (p<0.001) but not for curative treatment (not reached vs. 38.3 months) (p=0.038).

CONCLUSION

Timely treatment is not necessarily associated with improved survival.

Factors associated with emergency-related diagnosis, time to treatment and type of treatment in 5713 lung cancer patients

Background

International and national differences exist in survival among lung cancer patients. Possible explanations include varying proportions of emergency presentations (EPs), unwanted differences in waiting time to treatment and unequal access to treatment.

Methods

Case-mix-adjusted multivariable logistic regressions the odds of EP and access to surgery, radiotherapy and systemic anticancer treatment (SACT). Multivariable quantile regression analyzed time from diagnosis to first treatment.

Results

Of 5713 lung cancer patients diagnosed in Norway in 2015–16, 37.9% (n = 2164) had an EP before diagnosis. Higher age, more advanced stage and more comorbidities were associated with increasing odds of having an EP (P < 0.001) and a lower odds of receiving any treatment (P < 0.001). After adjusting for case-mix, waiting times to curative radiotherapy and SACT were 12.1 days longer [95% confidence interval (CI): 10.2, 14.0] and 5.6 days shorter (95% CI: −7.3, −3.9), respectively, compared with waiting time to surgery. Patients with regional disease experienced a 4.7-day shorter (Coeff: −4.7, 95% CI:−9.4, 0.0) waiting time to curative radiotherapy when compared with patients with localized disease. Patients with a high income had a 22% reduced odds [odds ratio (OR) = 0.78, 95% CI: 0.63, 0.97] of having an EP, and a 63% (OR = 1.63, 95% CI: 1.20, 2.21) and a 40% (OR = 1.40, 95% CI: 1.12, 1.76) increased odds of receiving surgery and SACT, respectively.

Conclusion

Patients who were older, had advanced disease or increased comorbidities were more likely to have an EP and less likely to receive treatment. While income did not affect the waiting time for lung cancer treatment in Norway, it did affect the likelihood of receiving surgery and SACT.

Understanding the patient journey to diagnosis of lung cancer

Objective

This research describes the clinical pathway and characteristics of two cohorts of patients. The first cohort consists of patients with a confirmed diagnosis of lung cancer while the second consists of patients with a solitary pulmonary nodule (SPN) and no evidence of lung cancer. Linked data from an electronic medical record and the Louisiana Tumor Registry were used in this investigation.

Materials and methods

REACHnet is one of 9 clinical research networks (CRNs) in PCORnet®, the National Patient-Centered Clinical Research Network and includes electronic health records for over 8 million patients from multiple partner health systems. Data from Ochsner Health System and Tulane Medical Center were linked to Louisiana Tumor Registry (LTR), a statewide population-based cancer registry, for analysis of patient’s clinical pathways between July 2013 and 2017. Patient characteristics and health services utilization rates by cancer stage were reported as frequency distributions. The Kaplan-Meier product limit method was used to estimate the time from index date to diagnosis by stage in lung cancer cohort.

Results

A total of 30,559 potentially eligible patients were identified and 2929 (9.58%) had primary lung cancer. Of these, 1496 (51.1%) were documented in LTR and their clinical pathway to diagnosis was further studied. Time to diagnosis varied significantly by cancer stage. A total of 24,140 patients with an SPN were identified in REACHnet and 15,978 (66.6%) had documented follow up care for 1 year. 1612 (10%) had no evidence of any work up for their SPN. The remaining 14,366 had some evidence of follow up, primarily office visits and additional chest imaging.

Conclusion

In both cohorts multiple biopsies were evident in the clinical pathway. Despite clinical workup, 70% of patients in the lung cancer cohort had stage III or IV disease. In the SPN cohort, only 66% were identified as receiving a diagnostic work-up.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08067-1.

Factors influencing the delivery of cancer pathways: a summary of the literature

PURPOSE

The study aims to summarise the literature on cancer care pathways at the diagnostic and treatment phases. The objectives are to find factors influencing the delivery of cancer care pathways; to highlight any interrelating factors; to find gaps in the literature concerning areas of research; to summarise the strategies and recommendations implemented in the studies.

DESIGN/METHODOLOGY/APPROACH

The study used a qualitative approach and developed a causal loop diagram to summarise the current literature on cancer care pathways, from screening and diagnosis to treatment. A total of 46 papers was finally included in the analysis, which highlights the recurring themes in the literature.

FINDINGS

The study highlights the myriad areas of research applied to cancer care pathways. Factors influencing the delivery of cancer care pathways were classified into different albeit interrelated themes. These include access barriers to care, hospital emergency admissions, fast track diagnostics, delay in diagnosis, waiting time to treatment and strategies to increase system efficiency.

ORIGINALITY/VALUE

As far as the authors know, this is the first study to present a visual representation of the complex relationship between factors influencing the delivery of cancer care pathways.

Head and Neck Cancer Treatments from Chemotherapy to Magnetic Systems: Perspectives and Challenges

BACKGROUND

Cancer is one of the diseases causing society's fears as a stigma of death and pain. Head and Neck Squamous Cell Carcinoma (HNSCC) is a group of malignant neoplasms of different locations in this region of the human body. It is one of the leading causes of morbidity and mortality in Brazil, because these malignant neoplasias, in most cases, are diagnosed in late phases. Surgical excision, chemotherapy and radiotherapy encompass the forefront of antineoplastic therapy; however, the numerous side effects associated with these therapeutic modalities are well known. Some treatments present enough potential to help or replace conventional treatments, such as Magnetic Hyperthermia and Photodynamic Therapy. Such approaches require the development of new materials at the nanoscale, able to carry out the loading of their active components while presenting characteristics of biocompatibility mandatory for biomedical applications.

OBJECTIVE

This work aims to make a bibliographical review of HNSCC treatments. Recent techniques proven effective in other types of cancer were highlighted and raised discussion and reflections on current methods and possibilities of enhancing the treatment of HNSCC.

METHOD

The study was based on a bibliometric research between the years 2008 and 2019 using the following keywords: Cancer, Head and Neck Cancer, Chemotherapy, Radiotherapy, Photodynamic Therapy, and Hyperthermia.

RESULTS

A total of 5.151.725 articles were found, 3.712.670 about cancer, 175.470 on Head and Neck Cancer, 398.736 on Radiotherapy, 760.497 on Chemotherapy, 53.830 on Hyperthermia, and 50.522 on Photodynamic Therapy.

CONCLUSION

The analysis shows that there is still much room for expanding research, especially for alternative therapies since most of the studies still focus on conventional treatments and on the quest to overcome their side effects. The scientific community needs to keep looking for more effective therapies generating fewer side effects for the patient. Currently, the so-called alternative therapies are being used in combination with the conventional ones, but the association of these new therapies shows great potential, in other types of cancer, to improve the treatment efficacy.

Time from presentation to pre-diagnostic chest X-ray in patients with symptomatic lung cancer: a cohort study using electronic patient records from English primary care

BACKGROUND

National guidelines in England recommend prompt chest X-ray (within 14 days) in patients presenting in general practice with unexplained symptoms of possible lung cancer, including persistent cough, shortness of breath, or weight loss.

AIM

To examine time to chest X-ray in symptomatic patients in English general practice before lung cancer diagnosis, and explore demographical variation.

DESIGN AND SETTING

Retrospective cohort study using routinely collected general practice, cancer registry, and imaging data from England.

METHOD

Patients with lung cancer who presented symptomatically in general practice in the year pre-diagnosis and who had a pre-diagnostic chest X-ray were included. Time from presentation to chest X-ray (presentation-test interval) was determined and intervals classified based on national guideline recommendations as concordant (≤14 days) or non-concordant (>14 days). Variation in intervals was examined by age, sex, smoking status, and deprivation.

RESULTS

In a cohort of 2102 patients with lung cancer, the median presentation-test interval was 49 (interquartile range [IQR] 5-172) days. Of these, 727 (35%) patients had presentation-test intervals of ≤14 days (median 1 [IQR 0-6] day) and 1375 (65%) had presentation-test intervals of >14 days (median 128 [IQR 52-231] days). Intervals were longer among patients who smoke (equivalent to 63% longer than non-smokers; P<0.001), older patients (equivalent to 7% longer for every 10 years from age 27; P = 0.013), and females (equivalent to 12% longer than males; P = 0.016).

CONCLUSION

In symptomatic primary care patients who underwent chest X-ray before lung cancer diagnosis, only 35% were tested within the timeframe recommended by national guidelines. Patients who smoke, older patients, and females experienced longer intervals. These findings could help guide initiatives aimed at improving timely lung cancer diagnosis.

Age-related and socioeconomic inequalities in timeliness of referral and start of treatment in colorectal cancer: a population-based analysis

BACKGROUND

Poorer colorectal cancer survival in the UK than in similar countries may be partly due to delays in the care pathway. To address this, cancer waiting time targets were established. We investigated if socio-demographic inequalities exist in meeting cancer waiting times for colorectal cancer.

METHODS

We identified primary colorectal cancers (International Classification of Diseases, Tenth Revision C18-C20; n=35 142) diagnosed in the period 2001-2010 in the Northern and Yorkshire Cancer Registry area. Using multivariable logistic regression, we calculated likelihood of referral and treatment within target by age group and deprivation quintile.

RESULTS

48% of the patients were referred to hospital within target (≤14 days from general practitioner (GP) referral to first hospital appointment); 52% started treatment within 31 days of diagnosis; and 44% started treatment within 62 days of GP referral. Individuals aged 60-69, 70-79 and 80+ years were significantly more likely to attend a first hospital appointment within 14 days than those aged <60 years (adjusted OR=1.23, 95% CI 1.12 to 1.34; adjusted OR=1.19, 95% CI 1.09 to 1.29; adjusted OR=1.30, 95% CI 1.18 to 1.42, respectively). Older age was significantly associated with lower likelihood of starting treatment within 31 days of diagnosis and 62 days of referral. Deprivation was not related to referral within target but was associated with lower likelihood of starting treatment within 31 days of diagnosis or 62 days of referral (most vs least: adjusted OR=0.82, 95% CI 0.74 to 0.91).

CONCLUSIONS

Older patients with colorectal cancer were less likely to experience referral delays but more likely to experience treatment delays. More deprived patients were more likely to experience treatment delays. Investigation of patient pathways, treatment decision-making and treatment planning would improve understanding of these inequalities.

Influence of timeliness and receipt of first treatment on geographic variation in non-small cell lung cancer mortality

Mortality from non-small cell lung cancer (NSCLC) exhibits substantial geographical disparities. However, there is little evidence on whether this variation could be attributed to patients' clinical characteristics and/or socioeconomic inequalities. This study evaluated the independent and relative contribution of the individual- and area-level risk factors on geographic variation in 2-year all-cause mortality among NSCLC patients. In the Hierarchical-related regression approach, we used the Bayesian spatial multilevel logistic regression model to combine individual- and area-level predictors with outcomes while accounting for geographically structured and unstructured correlation. Individual-level data included 3330 NSCLC cases reported to the Victoria Lung Cancer Registry between 2011 and 2016. Area-level data comprised socioeconomic disadvantage, remoteness and pollution data at the postal area level in Victoria, Australia. With the inclusion of significant individual- and area-level risk factors, timely (≤14 days) first definitive treatment (odds ratio [OR] = 0.73, 95% credible interval [Crl] = 0.56-0.94) and multidisciplinary meetings (MDM) (OR = 0.74, 95% Crl = 0.59-0.93) showed an independent association with a lower likelihood of NSCLC 2-year all-cause mortality. Timely and delayed (>14 days) first nondefinitive treatment, no treatment, advanced clinical stage, smoking, poor performance status, public hospital insurance and area-level deprivation were independently associated with a higher likelihood of 2- and 5-year all-cause mortality. NSCLC's 2-year all-cause mortality exhibited substantial geographic variation, mainly associated with timeliness and receipt of first definitive treatment, no treatment followed by patient prognostic factors with some contribution from area-level deprivation, MDM and public hospital insurance. This study highlights NSCLC patients should receive the first definitive treatment within the recommended 14-days from diagnosis.

Reasons for prolonged time for diagnostic workup for stage I-II lung cancer and estimated effect of applying an optimized pathway for diagnostic procedures

BACKGROUND

Minimizing the time until start of cancer treatment is a political goal. In Norway, the target time for lung cancer is 42 days. The aim of this study was to identify reasons for delays and estimate the effect on the timelines when applying an optimal diagnostic pathway.

METHODS

Retrospective review of medical records of lung cancer patients, with stage I-II at baseline CT, receiving curative treatment (n = 100) at a regional cancer center in Norway.

RESULTS

Only 40% started treatment within 42 days. The most important delays were late referral to PET CT (n = 27) and exercise test (n = 16); repeated diagnostic procedures because bronchoscopy failed (n = 15); and need for further investigations after PET CT (n = 11). The time from referral to PET CT until the final report was 20.5 days in median. Applying current waiting time for PET CT (≤7 days), 48% would have started treatment within 42 days (p = 0.254). "Optimal pathway" was defined as 1) referral to PET CT and exercise test immediately after the CT scan and hospital visit, 2) tumor board discussion to decide diagnostic strategy and treatment, 3) referral to surgery or curative radiotherapy, 4) tissue sampling while waiting to start treatment. Applying the optimal pathway, current waiting time for PET CT and observed waiting times for the other procedures, 80% of patients could have started treatment within 42 days (p < 0.001), and the number of tissue sampling procedures could have been reduced from 112 to 92 (- 16%).

CONCLUSION

Changing the sequence of investigations would significantly reduce the time until start of treatment in curative lung cancer patients at our hospital and reduce the resources needed.

Establishing population-based surveillance of diagnostic timeliness using linked cancer registry and administrative data for patients with colorectal and lung cancer

BACKGROUND

Diagnostic timeliness in cancer patients is important for clinical outcomes and patient satisfaction but, to-date, continuous monitoring of diagnostic intervals in nationwide incident cohorts has been impossible in England.

METHODS

We developed a new methodology for measuring the secondary care diagnostic interval (SCDI - first relevant secondary care contact to diagnosis) using linked cancer registration and healthcare utilisation data. Using this method, we subsequently examined diagnostic timeliness in colorectal and lung cancer patients (2014-15) by socio-demographic characteristics, diagnostic route and stage at diagnosis.

RESULTS

The approach assigned SCDIs to 94.4% of all incident colorectal cancer cases [median length (90th centile) of 25 (104) days] and 95.3% of lung cancer cases [36 (144) days]. Advanced stage patients had shorter intervals (median, colorectal: stage 1 vs 4 - 34 vs 19 days; lung stage 1&2 vs 3B&4 - 70 vs 27 days). Routinely referred patients had the longest (colorectal: 61, lung: 69 days) and emergency presenters the shortest intervals (colorectal: 3, lung: 14 days). Comorbidities and additional diagnostic tests were also associated with longer intervals.

CONCLUSION

This new method can enable repeatable nationwide measurement of cancer diagnostic timeliness in England and identifies actionable variation to inform early diagnosis interventions and target future research.

[The impact of the patient's age on the delay of the lung cancer treatment]

INTRODUCTION

The results from the medical literature regarding the influence of patient's age on the delay of treatment in lung cancer are controversial in the absence of a consensual definition. The aim of this study was to determine the impact of the patient's age on the delay of the lung cancer treatment.

METHODS

A retrospective monocentric study was performed including patients treated for a lung cancer in our department between November 1, 2014 and October 31, 2015. The delay of treatment was defined by the delay between the first abnormal imaging and the first treatment. The patients were divided into three groups depending on their age: group 1 with≤60 years old, group 2 between 60 and 70 years old, and group 3 with>70 years old. The statistical analysis was realized with Pearson's chi-squared and the Anova tests.

RESULTS

Two-hundred and forty-six patients were included with a mean age at 65±10 years. The mean delay of the treatment was 97±41 days. The mean delay of the treatment in patients with>70 years old was statically longer than the delay of treatment in patients with≤60 years old (116±98 days vs. 76±65 days, P=0.04), secondary to an extended time for the lung cancer surgery (129±75 days vs. 88±54 days, P=0.03).

CONCLUSION

In patients with>70 years old, the delay of treatment is longer than in other groups, secondary to an extended time for the preoperative assessment. An improvement in therapeutic management is necessary in our care system to shorten this delay.

Predicting delays in lung cancer diagnosis and staging

Background

Despite growing interest in increasing the efficiency and speed of the diagnosis, staging, and treatment of lung cancer (LC), the interval from signs and symptoms to diagnosis and treatment remains longer than recommended. The aim of this study was to analyze the factors that cause delays in the LC diagnosis/staging process and, consequently, delays in making therapeutic decisions.

Methods

We analyzed audit data from a prospective dataset of 1330 patients assessed at The Lung Cancer Rapid Diagnostic Unit from 26 June 2013 to 26 March 2016. The number and type of procedures and medical tests and the times of all procedures were recorded. Clinical and epidemiological variables and whether the diagnosis was performed on an inpatient or outpatient basis were also recorded.

Results

Malignancy was confirmed in 737 (55.4%) of the 1330 patients, with LC in 627 of these (85.2%). The mean interval to final diagnosis was 19.8 ± 13.9 days. Variables significantly related to a longer diagnostic time were the number of days until computed tomography (CT) was performed (odds ratio [OR], 95% confidence interval [CI] 1.347, 1.103–1.645; P = 0.003), until a histology sample was obtained (OR 1.243, 95% CI1.062–1.454; P = 0.007), and the total number of tests performed during the diagnostic and staging process (OR 1.823, 95% CI 1.046–3.177; P = 0.03).

Conclusions

A greater number of tests and more days to CT and histology led to longer delay times. Optimization of these factors should reduce delays in the LC diagnosis process.

Can we assess Cancer Waiting Time targets with cancer survival? A population-based study of individually linked data from the National Cancer Waiting Times monitoring dataset in England, 2009-2013

BACKGROUND

Cancer Waiting Time targets have been integrated into successive cancer strategies as indicators of cancer care quality in England. These targets are reported in national statistics for all cancers combined, but there is mixed evidence of their benefits and it is unclear if meeting Cancer Waiting Time targets, as currently defined and published, is associated with improved survival for individual patients, and thus if survival is a good metric for judging the utility of the targets.

METHODS AND FINDINGS

We used individually-linked data from the National Cancer Waiting Times Monitoring Dataset (CWT), the cancer registry and other routinely collected datasets. The study population consisted of all adult patients diagnosed in England (2009-2013) with colorectal (164,890), lung (171,208) or ovarian (24,545) cancer, of whom 82%, 76%, and 77%, respectively, had a CWT matching record. The main outcome was one-year net survival for all matched patients by target attainment ('met/not met'). The time to each type of treatment for the 31-day and 62-day targets was estimated using multivariable analyses, adjusting for age, sex, tumour stage and deprivation. The two-week wait (TWW) from GP referral to specialist consultation and 31-day target from decision to treat to start of treatment were met for more than 95% of patients, but the 62-day target from GP referral to start of treatment was missed more often. There was little evidence of an association between meeting the TWW target and one-year net survival, but for the 31-day and 62-day targets, survival was worse for those for whom the targets were met (e.g. colorectal cancer: survival 89.1% (95%CI 88.9-89.4) for patients with 31-day target met, 96.9% (95%CI 96.1-91.7) for patients for whom it was not met). Time-to-treatment analyses showed that treatments recorded as palliative were given earlier in time, than treatments with potentially curative intent. There are possible limitations in the accuracy of the categorisation of treatment variables which do not allow for fully distinguishing, for example, between curative and palliative intent; and it is difficult in these data to assess the appropriateness of treatment by stage. These limitations in the nature of the data do not affect the survival estimates found, but do mean that it is not possible to separate those patients for whom the times between referral, decision to treat and start of treatment could actually have an impact on the clinical outcomes. This means that the use of these survival measures to evaluate the targets would be misleading.

CONCLUSIONS

Based on these individually-linked data, and for the cancers we looked at, we did not find that Cancer Waiting Time targets being met translates into improved one-year survival. Patients may benefit psychologically from limited waits which encourage timely treatment, but one-year survival is not a useful measure for evaluating Trust performance with regards to Cancer Waiting Time targets, which are not currently stratified by stage or treatment type. As such, the current composition of the data means target compliance needs further evaluation before being used for the assessment of clinical outcomes.

Sociodemographic variation in the use of chemotherapy and radiotherapy in patients with stage IV lung, oesophageal, stomach and pancreatic cancer: evidence from population-based data in England during 2013-2014

BACKGROUND

Sociodemographic inequalities in cancer treatment have been generally described, but there is little evidence regarding patients with advanced cancer. Understanding variation in the management of these patients may provide insights into likely mechanisms leading to inequalities in survival.

METHODS

We identified 50,232 patients with stage IV lung, oesophageal, pancreatic and stomach cancer from the English national cancer registry. A generalised linear model with a Poisson error structure was used to explore variation in radiotherapy and chemotherapy within 6 months from diagnosis by age, sex, deprivation, ethnicity, cancer site, comorbidity and, additionally, performance status.

RESULTS

There was substantial variation by cancer site, large gradients by age, and non-trivial associations with comorbidity and deprivation. After full adjustment, more deprived patients were consistently least likely to be treated with chemotherapy alone or chemotherapy and radiotherapy combined compared with less deprived patients with equally advanced disease stage (treatment rate ratio: 0.82 95% CI (0.78, 0.87) for CT, 0.78 95% CI (0.71, 0.85) for CTRT p < 0.0001).

CONCLUSIONS

There was marked variation in the management of patients with stage IV cancer. Routinely collected data could be used for surveillance across all cancers to help reduce treatment variation and optimise outcomes among patients with advanced cancer.

Which patients are not included in the English Cancer Waiting Times monitoring dataset, 2009-2013? Implications for use of the data in research

BACKGROUND

Cancer waiting time targets are routinely monitored in England, but the Cancer Waiting Times monitoring dataset (CWT) does not include all eligible patients, introducing scope for bias.

METHODS

Data from adults diagnosed in England (2009-2013) with colorectal, lung, or ovarian cancer were linked from CWT to cancer registry, mortality, and Hospital Episode Statistics data. We present demographic characteristics and net survival for patients who were and were not included in CWT.

RESULTS

A CWT record was found for 82% of colorectal, 76% of lung, and 77% of ovarian cancer patients. Patients not recorded in CWT were more likely to be in the youngest or oldest age groups, have more comorbidities, have been diagnosed through emergency presentation, have late or missing stage, and have much poorer survival.

CONCLUSIONS

Researchers and policy-makers should be aware of the limitations in the completeness and representativeness of CWT, and draw conclusions with appropriate caution.

Impact of rapid investigation clinic on timeliness of lung cancer diagnosis and treatment

BACKGROUND

Guidelines recommend timely evaluation of patients with suspected lung cancer. We evaluated the impact of a Rapid Investigation Clinic (RIC) on timeliness of lung cancer diagnosis and treatment between February 2010 and December 2011.

METHODS

Investigation within the RIC was conducted by a pulmonologist and a nurse clinician. Controls were patients with lung cancer, investigated outside the RIC at the same institution during the same time period. The primary outcome was time between first contact with a local physician for suspected lung cancer (T0) and first treatment. Factors associated with the delay from T0 to first treatment were examined using multivariate analysis. Completeness of lung cancer staging according to guidelines was assessed.

RESULTS

A total of 195 patients were investigated within the RIC vs. 132 patients outside the RIC. The median delay between T0 and first treatment was 65 days (interquartile range [IQR] 46-92 days) in the RIC and 78 days (IQR 49-119 days) in the non-RIC patients (p ≤ 0.01). Time from T0 to pathological diagnosis was shorter in the RIC (median 26 days; IQR 14-42 days) vs. non-RIC patients (median 40 days; IQR 16-68 days). In multivariate analysis, investigation in the RIC was associated with a reduction in time to first treatment of 24 days (95% confidence interval [CI] 12-35 days) when adjusted for relevant confounders. Guideline-concordant investigation occurred more frequently in RIC patients, based on the quality indicators examined.

CONCLUSIONS

A Rapid Investigation Clinic reduces delays to lung cancer diagnosis and treatment, and impacts quality of care.

Lung cancer care trajectory at a Canadian centre: an evaluation of how wait times affect clinical outcomes

BACKGROUND

Lung cancer continues to be one of the most common cancers in Canada, with approximately 28,400 new cases diagnosed each year. Although timely care can contribute substantially to quality of life for patients, it remains unclear whether it also improves patient outcomes. In this work, we used a set of quality indicators that aim to describe the quality of care in lung cancer patients. We assessed adherence with existing guidelines for timeliness of lung cancer care and concordance with existing standards of treatment, and we examined the association between timeliness of care and lung cancer survival.

METHODS

Patients with lung cancer diagnosed between 2010 and 2015 were identified from the Pulmonary Division Lung Cancer Registry at our centre.

RESULTS

We demonstrated that the interdisciplinary pulmonary oncology service successfully treated most of its patients within the recommended wait times. However, there is still work to be done to decrease variation in wait time. Our results demonstrate a significant association between wait time and survival, supporting the need for clinicians to optimize the patient care trajectory.

INTERPRETATION

It would be helpful for Canadian clinicians treating patients with lung cancer to have wait time guidelines for all treatment modalities, together with standard definitions for all time intervals. Any reductions in wait times should be balanced against the need for thorough investigation before initiating treatment. We believe that our unique model of care leads to an acceleration of diagnostic steps. Avoiding any delay associated with referral to a medical oncologist for treatment could be an acceptable strategy with respect to reducing wait time.

Prognostic consequences of implementing cancer patient pathways in Denmark: a comparative cohort study of symptomatic cancer patients in primary care

BACKGROUND

Cancer Patient Pathways (CPPs) were introduced in 2000-2015 in several European countries, including Denmark, to reduce the time to diagnosis and treatment initiation and ultimately improve patient survival. Yet, the prognostic consequences of implementing CPPs remain unknown for symptomatic cancer patients diagnosed through primary care. We aimed to compare survival and mortality among symptomatic patients diagnosed through a primary care route before, during and after the CPP implementation in Denmark.

METHODS

Based on data from the Danish Cancer in Primary Care (CaP) Cohort, we compared one- and three-year standardised relative survival (RS) and excess hazard ratios (EHRs) before, during and after CPP implementation for seven types of cancer and all combined (n = 7725) by using life-table estimation and Poisson regression. RS estimates were standardised according to the International Cancer Survival Standard (ICSS) weights. In addition, we compared RS and EHRs for CPP and non-CPP referred patients to consider potential issues of confounding by indication.

RESULTS

In total, 7725 cases were analysed: 1202 before, 4187 during and 2336 after CPP implementation. For all cancers combined, the RS3years rose from 45% (95% confidence interval (CI): 42;47) before to 54% (95% CI: 52;56) after CPP implementation. The excess mortality was higher before than after CPP implementation (EHR3years before vs. after CPP = 1.35 (95% CI: 1.21;1.51)). When comparing CPP against non-CPP referred patients, we found no statistically significant differences in RS, but we found lower excess mortality among the CPP referred (EHR1year CPP vs. non-CPP = 0.86 (95% CI: 0.73;1.01)).

CONCLUSION

We found higher relative survival and lower mortality among symptomatic cancer patients diagnosed through primary care after the implementation of CPPs in Denmark. The observed changes in cancer prognosis could be the intended consequences of finding and treating cancer at an early stage, but they may also reflect lead-time bias and selection bias. The finding of a lower excess mortality among CPP referred compared to non-CPP referred patients indicates that CPPs may have improved the cancer prognosis independently.

Study on Inhibitory Effect of MaiMenDong Decoction and WeiJing Decoction Combination with Cisplatin on NCI-A549 Xenograft in Nude Mice and Its Mechanism

MaiMenDong Decoction and WeiJing Decoction (Jin formula) is a traditional Chinese medication that consists of 8 medicinal plants, which recorded in the classical TCM literature Jin Kui Yao Lue and has been utilized in the treatment of lung diseases for hundreds of years in China. The present study aimed to determine the anti-tumor activity and the underlying mechanisms of Jin formula combined with cisplatin in the treatment of non-small cell lung cancer (NSCLC). Xenograft model of NCI-A549 was established in Balb/c nude mice. Five groups, including normal, MOCK, Jin, cisplatin (DDP), and Jin+DDP were included in the study. We found that Jin formula ameliorated the body weight loss caused by DDP 15 days after drug administration. Moreover, the combination of Jin with DDP enhanced the anti-tumor function of DDP. Microarray analysis showed that Jin suppressed gene expression of certain pathways which regulating cell cycle and apoptosis. Furthermore, DDP mainly decreased the gene expression level of angiogenesis associated factors, such as VEGFA, TGF-β and MMP-1. Moreover, co-treatment with Jin and DDP not only down-regulated Bcl-2 and E2F1, but also decreased the expression of MYC, MET, and MCAM. In addition, co-formula decreased the levels of p-AKT (thr308) and p-PTEN, increased Bax/Bcl-2 value, and resulted in apoptosis of tumor cells. Taken together, Jin+DDP significantly inhibited the growth of A549 cell transplanted solid tumor with slight side effect compared to the treatment by DDP only, and had a better effect than the Jin group. The mechanisms may be mainly associated with inactivation of PI3K/AKT pathway and apoptosis induction.

Socio-economic inequalities in stage at diagnosis, and in time intervals on the lung cancer pathway from first symptom to treatment: systematic review and meta-analysis

Cancer diagnosis at an early stage increases the chance of curative treatment and of survival. It has been suggested that delays on the pathway from first symptom to diagnosis and treatment may be socio-economically patterned, and contribute to socio-economic differences in receipt of treatment and in cancer survival. This review aimed to assess the published evidence for socio-economic inequalities in stage at diagnosis of lung cancer, and in the length of time spent on the lung cancer pathway. MEDLINE, EMBASE and CINAHL databases were searched to locate cohort studies of adults with a primary diagnosis of lung cancer, where the outcome was stage at diagnosis or the length of time spent within an interval on the care pathway, or a suitable proxy measure, analysed according to a measure of socio-economic position. Meta-analysis was undertaken when there were studies available with suitable data. Of the 461 records screened, 39 papers were included in the review (20 from the UK) and seven in a final meta-analysis for stage at diagnosis. There was no evidence of socio-economic inequalities in late stage at diagnosis in the most, compared with the least, deprived group (OR=1.04, 95% CI=0.92 to 1.19). No socio-economic inequalities in the patient interval or in time from diagnosis to treatment were found. Socio-economic inequalities in stage at diagnosis are thought to be an important explanatory factor for survival inequalities in cancer. However, socio-economic inequalities in stage at diagnosis were not found in a meta-analysis for lung cancer.

PROSPERO PROTOCOL REGISTRATION NUMBER

CRD42014007145.

Transfer between hospitals as a predictor of delay in diagnosis and treatment of patients with Non-Small Cell Lung Cancer - a register based cohort-study

Background

Lung cancer is the second most frequent cancer diagnosis in Denmark. Although improved during the last decade, the prognosis of lung cancer is still poor with an overall 5-year survival rate of approximately 12%. Delay in diagnosis and treatment of lung cancer has been suggested as a potential cause of the poor prognosis and as consequence, fast track cancer care pathways were implemented describing maximum acceptable time thresholds from referral to treatment. In Denmark, patients with lung cancer are often transferred between hospitals with diagnostic facilities to hospitals with treatment facilities during the care pathway. We wanted to investigate whether this organizational set-up influenced the time that patients wait for the diagnosis and treatment. Therefore, the objective of this study was to uncover the impact of transfer between hospitals on the delay in the diagnosis and treatment of Non-Small Cell Lung Cancer (NSCLC).

Methods

We performed a historical prospective cohort study using data from the Danish Lung Cancer Registry (DLCR). All patients diagnosed with primary NSCLC from January 1st 2008 to December 31st 2012 were included. Patients with unresolved pathology and incomplete data on the dates of referral, diagnosis and treatment were excluded.

Results

A total of 11 273 patients were included for further analyses. Transfer patients waited longer for treatment after the diagnosis, (Hazard ratio (HR) 0.81 (0.68–0.96)) and in total time from referral to treatment (HR 0.84 (0.77–0.92)), than no-transfer patients. Transfer patients had lower odds of being diagnosed (Odds Ratio (OR) 0.82 (0.74–0.94) and treated (OR 0.66 (0.61–0.72) within the acceptable time thresholds described in the care pathway.

Conclusion

Fast track cancer care pathways were implemented to unify and accelerate the diagnosis and treatment of cancer. We found that the transfer between hospitals during the care pathway might cause delay from diagnosis to treatment as well as in the total time from referral to treatment in patients with Non Small-Cell Lung Cancer. The difference between no-transfer and transfer patients persists after adjusting for known predictors of delay.

A prognostic predictor panel with DNA methylation biomarkers for early-stage lung adenocarcinoma in Asian and Caucasian populations

Background

The incidence of lung adenocarcinoma (LUAD) is increasing worldwide with different prognosis even in early-stage patients. We aimed to identify a prognostic panel with multiple DNA methylation biomarkers to predict survival in early-stage LUAD patients of different racial groups.

Methods

The methylation array, pyrosequencing methylation assay, Cox regression and Kaplan-Meier analyses were conducted to build the risk score equations of selected probes in a training cohort of 69 Asian LUAD patients. The risk score model was verified in another cohort of 299 Caucasian LUAD patients in The Cancer Genome Atlas (TCGA) database.

Results

We performed a Cox regression analysis, in which the regression coefficients were obtained for eight probes corresponding to eight genes (AGTRL1, ALDH1A3, BDKRB1, CTSE, EFNA2, NFAM1, SEMA4A and TMEM129). The risk score was derived from sum of each methylated probes multiplied by its corresponding coefficient. Patients with the risk score greater than the median value showed poorer overall survival compared with other patients (p = 0.007). Such a risk score significantly predicted patients showing poor survival in TCGA cohort (p = 0.036). A multivariate analysis was further performed to demonstrate that the eight-probe panel association with poor outcome in early-stage LUAD patients remained significant even after adjusting for different clinical variables including staging parameters (hazard ratio, 2.03; p = 0.039).

Conclusions

We established a proof-of-concept prognostic panel consisting of eight-probe signature to predict survival of early-stage LUAD patients of Asian and Caucasian populations.

Electronic supplementary material

The online version of this article (doi:10.1186/s12929-016-0276-x) contains supplementary material, which is available to authorized users.

Outcomes after Stereotactic Body Radiotherapy versus Limited Resection in Older Patients with Early-Stage Lung Cancer

BACKGROUND

Limited resection and stereotactic body radiotherapy (SBRT) have emerged as treatment options for older patients with early-stage non-small-cell lung cancer (NSCLC), who are not good candidates for lobectomy.

METHODS

We used the Surveillance, Epidemiology and End Results-Medicare registry to identify patients older than 65 years with stage I to II NSCLC and negative lymph nodes treated with SBRT versus limited resection. We fitted a propensity score model predicting the use of SBRT and compared adjusted overall survival of patients treated with SBRT versus limited resection. Secondary analyses stratified the sample by type of limited resection (wedge versus segmentectomy), age (≤75 versus >75 years), and tumor size (<3 versus ≥3 cm). We also compared rates of surgical complications and SBRT-related toxicity in the two groups.

RESULTS

We identified 2243 patients of which 362 (16%) patients received SBRT. SBRT-treated patients were older, had higher comorbidity scores, and had larger tumors (p < 0.001 for all comparisons). Adjusted analyses showed no differences in survival (hazard ratio [HR], 1.19; 95% confidence interval [CI], 0.97-1.47) among patients treated with SBRT versus limited resection. Although survival of patients who underwent SBRT versus wedge resection was not different (HR, 1.22; 95% CI, 0.98-1.52), SBRT was associated with worse outcomes when compared with segmentectomy (HR, 1.55; 95% CI, 1.18-2.03). Adverse events were most often respiratory and more frequent in the patients treated with limited resection (28% versus 14%, p < 0.001).

CONCLUSION

SBRT is better tolerated and associated with similar survival when compared with wedge resection but not with segmentectomy in older patients with node-negative NSCLC.

Tumour stage and implementation of standardised cancer patient pathways: a comparative cohort study

BACKGROUND

Some European countries have introduced standardised cancer patient pathways (CPPs), including urgent referrals, with the aim of diagnosing cancer at an earlier stage. This is despite a lack of evidence, particularly in patients with symptomatic cancer diagnosed via general practice.

AIM

To compare tumour stages in patients with incident cancer diagnosed via general practice before, during, and after CPP implementation in Denmark in 2008-2009.

DESIGN AND SETTING

A comparative cohort study of data from GPs and registries on patients with incident cancer listed with a GP before (n = 1420), during (n = 5272), and after (n = 2988) CPP implementation.

METHOD

χ(2) test was used to compare stage distributions and logistic regression to estimate odds ratios (OR) of having local cancer after versus before CPP implementation.

RESULTS

Distribution of tumour stages did not differ statistically significantly across time (P = 0.494) or between CPP use (P = 0.202). For all cancers combined, the OR of having local cancer after CPP implementation was 0.88 (95% confidence interval [CI] = 0.73 to 1.06) compared with before. For CPP-referred patients, the OR of having local cancer was 0.77 (95% CI = 0.62 to 0.94) compared with all patients before CPP implementation; the corresponding OR for non-CPP-referred patients was 0.96 (95% CI = 0.80 to 1.14).

CONCLUSION

No clear tendencies were observed confirming earlier detection of cancer after rather than before CPP implementation. CPP-referred patients had lower odds of having local cancer after CPP implementation than all patients before CPP implementation; this could be because the GPs refer patients who are 'more ill' as urgent referrals.

The expanding role of primary care in cancer control

The nature of cancer control is changing, with an increasing emphasis, fuelled by public and political demand, on prevention, early diagnosis, and patient experience during and after treatment. At the same time, primary care is increasingly promoted, by governments and health funders worldwide, as the preferred setting for most health care for reasons of increasing need, to stabilise health-care costs, and to accommodate patient preference for care close to home. It is timely, then, to consider how this expanding role for primary care can work for cancer control, which has long been dominated by highly technical interventions centred on treatment, and in which the contribution of primary care has been largely perceived as marginal. In this Commission, expert opinion from primary care and public health professionals with academic and clinical cancer expertise—from epidemiologists, psychologists, policy makers, and cancer specialists—has contributed to a detailed consideration of the evidence for cancer control provided in primary care and community care settings. Ranging from primary prevention to end-of-life care, the scope for new models of care is explored, and the actions needed to effect change are outlined. The strengths of primary care—its continuous, coordinated, and comprehensive care for individuals and families—are particularly evident in prevention and diagnosis, in shared follow-up and survivorship care, and in end-of-life care. A strong theme of integration of care runs throughout, and its elements (clinical, vertical, and functional) and the tools needed for integrated working are described in detail. All of this change, as it evolves, will need to be underpinned by new research and by continuing and shared multiprofessional development.