Is increased time to diagnosis and treatment in symptomatic cancer associated with poorer outcomes? Systematic review

Biomarkers Suitable for Early Detection of Intrathoracic Cancers in Primary Care: A Systematic Review

Intrathoracic cancers, including lung cancer, mesothelioma, and thymoma, present diagnostic challenges in primary care. Biomarkers could resolve some challenges. We synthesized evidence on biomarker performance for intrathoracic cancer detection in low-prevalence settings. A search in Embase and MEDLINE included studies that recruited participants with suspected intrathoracic cancer and reported on at least one diagnostic measure for a validated, noninvasive biomarker. Studies were excluded if participants were recruited based on a preestablished diagnosis. A total of 52 studies were included, reporting on 108 individual biomarkers and panels. Carcinoembryonic antigen, CYFRA 21-1, and VEGF were evaluated for lung cancer and mesothelioma. For lung cancer, carcinoembryonic antigen and CYFRA 21-1 were the most studied, with AUCs of 0.48 to -0.90 and 0.48 to -0.83, respectively. Pro-gastrin-releasing peptide (Pro-GRP) and neuron-specific enolase (NSE) had the highest negative predictive values (NPV) (98.2% and 96.9%, respectively), whereas Early Cancer Detection Test - Lung (Early CDT) and miRNA signature classifier panels showed NPVs of 99.3% and 99.0%, respectively, in smokers. For mesothelioma, fibrillin-3 and mesothelin plus osteopontin had AUCs of 0.93 and 0.91, respectively. Thymoma panels (binding AcHR + StrAb and binding AcHR + modulating AcHR + StrAb) had 100% NPVs in patients with myasthenia gravis. The review highlights the performance of some biomarkers. However, few were evaluated in low-prevalence settings. Further evaluation is necessary before implementing these biomarkers for intrathoracic cancers in primary care.

The Stockholm early detection of cancer study (STEADY-CAN): rationale, design, data collection, and baseline characteristics for 2.7 million participants

The Stockholm Early Detection of Cancer Study (STEADY-CAN) cohort was established to investigate strategies for early cancer detection in a population-based context within Stockholm County, the capital region of Sweden. Utilising real-world data to explore cancer-related healthcare patterns and outcomes, the cohort links extensive clinical and laboratory data from both inpatient and outpatient care in the region. The dataset includes demographic information, detailed diagnostic codes, laboratory results, prescribed medications, and healthcare utilisation data. Since its inception, STEADY-CAN has collected longitudinal data on 2,732,005 individuals aged ≥ 18 years old living in or having access to health care in Stockholm County during the years 2011-2021. Focusing on cancer, the cohort includes 140,042 (5.1%) individuals with incident cancer and a control group of 2,591,963 (94.9%) cancer-free individuals. The cohort's diverse adult population enables robust analyses of early symptom detection, incidental findings, and the impact of comorbidities on cancer diagnoses. Utilizing the wide range of available laboratory data and clinical variables allow for advanced statistical analyses and adjustments for important confounding factors. The cohort's primary focus is to improve understanding of the early diagnostic phase of cancer, offering a crucial resource for studying cancer detection in clinical practice. Its comprehensive data collection provides unique opportunities for research into comorbidities and cancer outcomes, making the cohort a useful resource for ongoing cancer surveillance and public health strategies. The present study gives a detailed description of the rationale for creating the STEADY-CAN cohort, its design, the data collection procedure, and baseline characteristics of collected data.

The influence of treatment intervals on prognosis in young breast cancer patients: Insights from the French National cohort

BACKGROUND

Suboptimal treatment delays is known to impact prognosis of patients with cancer but optimal timing in specific subgroups remains poorly studied. This study aimed to analyze treatment delays in young women treated for a breast cancer (BC) on and its impact on their prognosis using French Nationwide Data.

METHODS

Using the CAREPAT-YBC Cohort based on the French National Healthcare System Database, we analyzed disease-free survival (DFS) in 22,093 young women (18-45 years) who underwent either surgery-chemotherapy-radiotherapy pathway (adjuvant setting, 15,433 patients) or chemotherapy-surgery-radiotherapy pathway (neoadjuvant setting, 6660 patients), according to delays between the different pathways.

RESULTS

For the adjuvant chemotherapy-radiotherapy interval, the best timing was 17-31 days with increased risk above this delay. For the neoadjuvant setting, the optimal neoadjuvant chemotherapy-surgery interval was 17-31 days, while ≤15 days (HR 1.44, 95%CI 1.21-1.71) or ≥62 days (HR 2.07, 95%CI 1.36-3.15) showed poorer prognosis. Combining best timing into an "optimal pathway" was associated with respectively a 1.2-fold decreased risk for recurrence or mortality.

CONCLUSION

Optimizing treatment intervals enhance BC survival in younger age.

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.

Exploring the policy implementation of a holistic approach to cancer investigation in non-specific symptom pathways in England: An ethnographic study

OBJECTIVES

This study aimed to explore the policy implementation of non-specific symptom pathways within the English National Health Service.

METHODS

A multi-site ethnographic project was conducted in four hospitals that contained non-specific symptom pathways between November 2021 and February 2023. The research involved observation (44 h), interviews (n = 54), patient shadowing, and document review.

RESULTS

The study examined how the policy concept of 'holistic' care was understood and put into practice within four non-specific symptom pathways. Several challenges associated with providing holistic care were identified. One key challenge was the conflict between delivering holistic care and meeting timed targets, such as the Faster Diagnosis Standard, due to limited availability of imaging and diagnostic tools. The interpretation of a holistic approach varied among participants, with some acknowledging that the current model did not recognise holistic care beyond cancer exclusion. The findings also revealed a lack of clarity and differing opinions on the boundaries of holistic care, resulting in wide variation in NSS pathway implementation across health care providers. Additionally, holistic investigation of non-specific symptoms in younger patients were seen to pose difficulties due to younger patients' history of health anxiety or depression, as well as concerns over radiological risk exposure.

CONCLUSIONS

The study highlights the complexity of implementing non-specific symptom pathways in light of standardised timed cancer targets and local cancer policies. There is a need for appropriately funded organisational models of care that prioritise holistic care in a timely manner over solely meeting cancer targets. Decision-makers should also consider the role of non-specific symptom pathways within the broader context of chronic disease management, with a particular emphasis on expanding diagnostic capacity.

Recent progress in prompt molecular detection of liquid biopsy using Cas enzymes: innovative approaches for cancer diagnosis and analysis

Creating fast, non-invasive, precise, and specific diagnostic tests is crucial for enhancing cancer treatment outcomes. Among diagnostic methods, those relying on nucleic acid detection are highly sensitive and specific. Recent developments in diagnostic technologies, particularly those leveraging Clustered Regularly Interspaced Short Palindromic Repeats (CRISPR), are revolutionizing cancer detection, providing accurate and timely results. In clinical oncology, liquid biopsy has become a noninvasive and early-detectable alternative to traditional biopsies over the last two decades. Analyzing the nucleic acid content of liquid biopsy samples, which include Circulating Tumor Cells (CTCs), Circulating Tumor DNA (ctDNA), Circulating Cell-Free RNA (cfRNA), and tumor extracellular vesicles, provides a noninvasive method for cancer detection and monitoring. In this review, we explore how the characteristics of various Cas (CRISPR-associated) enzymes have been utilized in diagnostic assays for cancer liquid biopsy and highlight their main applications of innovative approaches in monitoring, as well as early and rapid detection of cancers.

Time between pancreatic cancer diagnosis and treatment initiation and survival in the U.S. Military Health System

BACKGROUND

Pancreatic cancer has a high case fatality and treatment is known to improve survival. It is unknown whether the time between diagnosis and treatment initiation (time-to-treatment) is related to survival. Access to medical care may influence both treatment receipt and timing. We examined the relationship between time-to-treatment and survival among patients with pancreatic adenocarcinoma treated in the equal access Military Health System.

METHODS

We used the MilCanEpi database to study a cohort of 806 men and women who were diagnosed with stage I-IV pancreatic adenocarcinoma between 1998 and 2014 and received either surgery or chemotherapy as primary treatment. Time-to-treatment in relation to overall survival was examined in multivariable time-dependent Cox regression models.

RESULTS

Overall, median time-to-treatment was 3 weeks and 95 % of patients received treatment within 12 weeks. Time-to-treatment >6 weeks was associated with a statistically significant lower risk of death (AHR = 0.77, 95 % CI = 0.61-0.98) compared to time-to-treatment <3 weeks. Analysis by the first treatment type showed that time-to-surgery was not associated with survival among those receiving upfront surgery. Time-to-chemotherapy of >6 weeks was associated with reduced risks of death compared to <3 weeks (AHR = 0.62, 95 % CI = 0.48-0.80) for patients receiving primary chemotherapy.

CONCLUSIONS

Our data suggests that longer time-to-treatment, especially among patients with chemotherapy, was associated with lower risk of death among patients with pancreatic adenocarcinoma who received treatment. Further research is needed to understand the association of intervals along the whole cancer spectrum (e.g., presentation, diagnosis, treatment) and longer treatment intervals (i.e., >12 weeks) with survival.

Ranking of Health Problems and Prioritization of Cancer Education Topics by African American Communities in South Carolina

Despite landmark breakthroughs in cancer research, African American adults (AA) bear the highest cancer burden compared to other racial groups in the United States (US). AA adults have twice the likelihood of dying from prostate and uterine cancers compared to White adults, suggesting that there are fundamental issues yet to be addressed when developing and implementing cancer-preventative programs for AA communities. Community-based participatory research (CBPR) empowers community members to identify and prioritize their health problems and preferred strategies to tackle these issues. In alignment with the CBPR approach, the South Carolina Cancer Disparities Research Center (SC CADRE) undertook a study to inform cancer research priorities and interventions. A survey designed by the SC CADRE team to assess perceptions about health problems (cancer risk factors), prioritization of cancer education topics, and attitudes related to cancer prevention was completed by predominantly AA community members in South Carolina (N = 179). Participants had a mean age of 51.59 ± 16.53 years; the majority were AA (72.49%), females (76.44%), had bachelor's/graduate degrees (66.29%), and were from the Lowcountry coastal region of the state (85.26%). Obesity emerged as the greatest health concern, followed by poor diet and low physical activity. The top three priorities for cancer education were to learn about causes of cancer, strategies for healthy eating, and how to access healthcare. These findings could inform cancer education and intervention programs to address the top priority health needs identified by AA communities in South Carolina. They may also be relevant in other states, especially in rural southern parts of the USA.

Primary Care Referral Delays in Oral Cancer Diagnosis: A Meta‐Analysis

Objective

To measure the primary care interval (PCI) in the diagnostic delay of oral cancer and to assess the relation of the referring physician's specialty with disease stage at diagnosis.

Methods

We meta‐analyzed reports of oral/oropharyngeal carcinomas detailing PCI start‐ and endpoints, i.e., the time needed by a primary care physician to refer a suspected oral cancer patient to a specialist.

Results

17 studies with a total of 2530 patients were eligible; nine provided data on the relative length of PCI, and 10 reported on the impact of the referring professional's specialty on oral cancer diagnostic delay. The average PCI length was slightly longer for general practitioners (GPs) (30.5 days) than for general dental practitioners (GDPs) (27.6 days), while that for the total group was 28.7 days. One‐third of the total pre‐hospital time spent on diagnosis elapses in GP practices (PCI%: 0.31 [95% CI: 0.23, 0.40]). GDPs refer their patients for treatment at earlier disease stages (TNM I‐II) than GPs (Odds Ratio: 0.58; 95% CI: 0.34–0.98).

Conclusions

Primary care accounts for a considerable pre‐hospital amount of time of what is necessary for reaching a diagnosis of oral cancer patients. This calls for enhancing early oral cancer recognition in primary care settings.

The impact of delay from diagnosis to surgery in endometrial cancer

PURPOSE

When oncological waiting lists are prolonged, gynecological oncology units are forced to delay operations, especially for endometrial cancer (EC) due to its good prognosis among gynecological cancers. The aim of this study is to evaluate the impact of delay in the oncological outcomes of these patients.

METHODS

This is a retrospective analysis of all women with EC treated in our clinic, 2012-2019. Delay was calculated as the time interval between histological diagnosis of endometrial biopsy and definite surgery. The cutoff point was set at 8 weeks. Patients' characteristics, treatment options and follow-up information were collected. Primary outcomes were the need of adjuvant treatment and survival rates.

RESULTS

259 Patients met the inclusion criteria. Based on the 8-week cutoff point, patients were divided into 2 groups: 119 underwent surgery up to 8 weeks (group A) and 140 over 8 weeks (group B). There was no statistical difference in the FIGO stage or the preoperative CA-125 levels between the two groups. However, patients in group A were younger, with lower body mass index (BMI) and less comorbidities. Furthermore, patients in group B had a significantly higher probability of receiving pelvic radiation with or without brachytherapy (p = 0.0053). Concerning survival rates, there was a statistically difference in disease-free (p = 0.0312), but no difference was found in overall survival (p = 0.146).

CONCLUSION

Delaying EC surgery over 8 weeks may not have an impact on the mortality of the patients, but increases the need of adjuvant pelvic radiation and worsens recurrence rates. As a result, patients experience more side effects which subsequently had negative impact on their quality of life.

Time to Surgery Does Not Affect the Survival Outcome in Patients with Perihilar Cholangiocarcinoma

BACKGROUND

The impact of time to surgery (TTS) on survival in patients with perihilar cholangiocarcinoma (PHC) is uncertain.

METHODS

Data from PHC patients scheduled for surgery between 2011 and 2020 were reviewed. Patients were grouped based on the median TTS, defined as the time from diagnosis to surgery. Survival outcomes were analyzed for all patients and those undergoing potentially curative resection (resection without distant metastasis).

RESULTS

Of 224 patients, the median TTS was 64 days (range 19-212), with the patients being divided into two groups: long-TTS group (TTS ≥64 days, n = 116) and short-TTS group (TTS <64 days, n = 108). The long-TTS group showed higher rates of preoperative biliary infection (52% vs. 33%; p = 0.004) and portal vein embolization (84% vs. 49%; p < 0.001) compared with the short-TTS group. Forty-seven patients (18%) had unresectable tumors or distant metastasis, with a median overall survival (OS) of 18 months. The rate of potentially curative resection tended to be lower in the long-TTS group (74%) compared with the short-TTS group (84%), although it was not statistically significant (p = 0.063). However, OS for the entire cohort was comparable between the long-TTS and short-TTS groups (median OS 40 vs. 36 months; p = 0.986). Multivariable analysis revealed that TTS was not associated with survival in patients who underwent potentially curative resection.

CONCLUSIONS

Although the potentially curative resection rate tended to be lower in the long-TTS group, TTS did not impact survival in patients undergoing potentially curative resection for PHC.

Analysis of early diagnostic pathway for prostate cancer in Slovenia

BACKGROUND

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Rapid diagnostic pathways for prostate cancer: A realist synthesis

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS/ RECOMMENDATIONS

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

The impact of DNA tumor viruses in low-to-middle income countries (LMICS): A literature review

DNA viruses are common in the human population and act as aetiological agents of cancer on a large scale globally. They include the human papillomaviruses (HPV), Epstein-Barr virus (EBV), Kaposi sarcoma-associated herpesvirus (KSHV), hepatitis viruses, and human polyomaviruses. Oncogenic viruses employ different mechanisms to induce cancer. Notably, cancer only develops in a minority of individuals who are infected, usually following protracted years of chronic infection. The human papillomaviruses (HPVs) are associated with the highest number of cancer cases, including cervical cancer and other epithelial malignancies. Hepatitis B virus (HBV) and the RNA virus hepatitis C (HCV) are significant contributors to hepatocellular cancer (HCC). Other oncoviruses include Epstein-Barr virus (EBV), Kaposi sarcoma-associated herpes virus (KSHV), human T-cell leukemia virus (HTLV-I), and Merkel cell polyomavirus (MCPyV). The identification of these infectious agents as aetiological agents for cancer has led to reductions in cancer incidence through preventive interventions such as HBV and HPV vaccination, HPV-DNA based cervical cancer screening, antiviral treatments for chronic HBV and HCV infections, and screening of blood for transfusion for HBV and HCV. Successful efforts to identify additional oncogenic viruses in human cancer may provide further understanding of the aetiology and development of cancer, and novel approaches for prevention and treatment. Cervical cancer, caused by HPV, is the leading gynaecological malignancy in LMICs, with high age-standardised incidence and mortality rates, HCC due to HBV is an important cause of cancer deaths, and the burden of other cancer attributable to infections continues to rise globally. Hence, cancers attributable to DNA viruses have become a significant global health challenge. These viruses hence warrant continued attention and interrogation as efforts to understand them further and device further preventive interventions are critical.

Misdiagnosis in breast imaging: a statement paper from European Society Breast Imaging (EUSOBI)-Part 1: The role of common errors in radiology in missed breast cancer and implications of misdiagnosis

IMPORTANCE

Misdiagnosis in breast imaging can have significant implications for patients, healthcare providers, and the healthcare system as a whole.

OBSERVATIONS

Some of the potential implications of misdiagnosis in breast imaging include delayed diagnosis or false reassurance, which can result in a delay in treatment and potentially a worse prognosis. Misdiagnosis can also lead to unnecessary procedures, which can cause physical discomfort, anxiety, and emotional distress for patients, as well as increased healthcare costs. All these events can erode patient trust in the healthcare system and in individual healthcare providers. This can have negative implications for patient compliance with screening and treatment recommendations, as well as overall health outcomes. Moreover, misdiagnosis can also result in legal consequences for healthcare providers, including medical malpractice lawsuits and disciplinary action by licensing boards.

CONCLUSION AND RELEVANCE

To minimize the risk of misdiagnosis in breast imaging, it is important for healthcare providers to use appropriate imaging techniques and interpret images accurately and consistently. This requires ongoing training and education for radiologists and other healthcare providers, as well as collaboration and communication among healthcare providers to ensure that patients receive appropriate and timely care. If a misdiagnosis does occur, it is important for healthcare providers to communicate with patients and provide appropriate follow-up care to minimize the potential implications of the misdiagnosis. This may include repeat imaging, additional biopsies or other procedures, and referral to specialists for further evaluation and management.

KEY POINTS

Question What factors most contribute to and what implications stem from misdiagnosis in breast imaging? Findings Ongoing training and education for radiologists and other healthcare providers, as well as interdisciplinary collaboration and communication, is paramount. Clinical relevance Misdiagnosis in breast imaging can have significant implications for patients, healthcare providers, and the entire healthcare system.

Association between surgery treatment delays and survival outcomes in patients with esophageal cancer in Hebei, China

Introduction

The delays in cancer therapies have the potential to impact disease progression by allowing the unchecked growth and spread of cancer cells. However, the understanding of the association between treatment waiting time and survival outcomes in patients with esophageal cancer (EC) is limited. This study aims to assess the impact of waiting time on survival outcomes among EC patients in Hebei province, which is recognized as one of the high-risk areas for EC in China.

Methods

A total of 9,977 non-metastatic EC patients who underwent surgical treatment were identified between 2000 and 2020. The survival outcomes of overall survival (OS) and cancer-specific survival (CSS) were determined using the Kaplan-Meier methodology. Univariate and multivariate Cox regression analysis was employed to evaluate the impact of treatment delays on OS and CSS.

Results

The average delay time for initiating EC surgical treatment after diagnosis was 1.31 months (95%CI=1.29-1.34). Patients with a long delay (≥ 3 months) in treatment, comprising 9977 EC patients, exhibited significantly lower rates of 3-, 5-, and 10-year OS and CSS compared to those without any delay in treatment initiation. A long delay in EC treatment independently associated with an elevated risk of all-cause and cancer-cause mortality among various patient subgroups, including males, older individuals, single individuals, low-income patients, residents of nonmetropolitan counties, as well as those diagnosed with poorly differentiated and stage IV EC.

Discussion

The long delay of treatment initiation impacts the outcomes of OS and CSS in EC patients. Optimizing treatment timing may enhance life expectancy for individuals diagnosed with EC.

Insurance remains a major source of disparity for patients with testicular cancer: call for advocacy

OBJECTIVE

To evaluate the effects of socioeconomic factors, including insurance status, on treatment and survival for patients with testicular cancer.

PATIENTS AND METHODS

We extracted a retrospective cohort from the National Cancer Database that included patients diagnosed with testicular cancer 2004-2020. Competing-risks and Cox regression multivariate models including demographic, pathological, and socioeconomic covariates were constructed to evaluate receipt of treatment and death, respectively.

RESULTS

A total of 95 955 patients with testicular cancer were identified. Compared with private insurance, Medicaid (sub-distribution hazard ratio [SHR] 0.70, P < 0.001), Medicare (SHR 0.73, P < 0.001), and uninsured (SHR 0.72, P < 0.001) patients were associated with decreased likelihood of receiving chemotherapy. Compared with private insurance, Medicaid (SHR 0.55, P < 0.001), Medicare (SHR 0.76, P-value <0.001), uninsured (SHR 0.63, P-value < 0.001), and other government insurance (SHR 0.71, P = 0.010) was associated with decreased likelihood of receiving radiation. Medicaid insurance status (reference private, HR 2.60, P < 0.001) conferred the second largest hazard of death, behind having Stage III disease (reference Stage 0). Compared with private insurance, Medicare (HR 2.20, P < 0.001), no insurance (HR 2.32, P < 0.001), and other government insurance (HR 1.53, P = 0.027) statuses had higher risk of death. Patients diagnosed in Medicaid-expansion states had lower all-cause mortality (11.4% vs 13.6%, P < 0.001).

CONCLUSIONS

Testicular cancer care relies on early diagnosis and treatment. It is critically important to have a healthcare system where individuals have access to insurance and are served equitably.

Variation in the use of primary care-led investigations prior to a cancer diagnosis: analysis of the National Cancer Diagnosis Audit

INTRODUCTION

Use of investigations can help support the diagnostic process of patients with cancer in primary care, but the size of variation between patient group and between practices is unclear.

METHODS

We analysed data on 53 252 patients from 1868 general practices included in the National Cancer Diagnosis Audit 2018 using a sequence of logistic regression models to quantify and explain practice-level variation in investigation use, accounting for patient-level case-mix and practice characteristics. Four types of investigations were considered: any investigation, blood tests, imaging and endoscopy.

RESULTS

Large variation in practice use was observed (OR for 97.5th to 2.5th centile being 4.02, 4.33 and 3.12, respectively for any investigation, blood test and imaging). After accounting for patient case-mix, the spread of practice variation increased further to 5.61, 6.30 and 3.60 denoting that patients with characteristics associated with higher use (ie, certain cancer sites) are over-represented among practices with lower than the national average use of such investigation. Practice characteristics explained very little of observed variation, except for rurality (rural practices having lower use of any investigation) and concentration of older age patients (practices with older patients being more likely to use all types of investigations).

CONCLUSION

There is very large variation between practices in use of investigation in patients with cancer as part of the diagnostic process. It is conceivable that the diagnostic process can be improved if investigation use was to be increased in lower use practices, although it is also possible that there is overtesting in practices with very high use of investigations, and in fact both undertesting and overtesting may co-exist.

Are delays in diagnosis and treatment of acute leukemia in a middle-income country associated with poor outcomes? A retrospective cohort study

INTRODUCTION

Acute leukemias (ALs) are aggressive diseases that lead to death without medical attention. We evaluated the association between delays in diagnosis and poor outcomes in AL by evaluating the symptom onset to treatment intervals in adults with newly diagnosed AL and their effect on an early death (ED).

METHODS

We assessed adults diagnosed with AL between 2015 and 2020 and evaluated baseline characteristics, the patient interval (PI), diagnostic interval (DI), treatment interval (TI) and the total time interval (TTI) to determine ED-associated factors.

MAIN RESULTS

We assessed 102 patients with acute lymphoblastic leukemia (ALL), 57 with acute myeloblastic leukemia (AML) and 29 with acute promyelocytic leukemia (APL). Median interval days were PI 14, DI 10, TI 4 and TTI 31.5. The TI and TTI intervals were lower in APL than in ALL and AML; TI 1 vs. 4 and 3 (p = 0.001) and TTI 21 vs. 31 and 35 (p = 0.016). The 30-day and 60-day EDs were 13.8% and 20.7%, mainly infections. ECOG > 2 (OR = 15.0) and PI < 7 days (OR = 4.06) were associated with 30-day ED; AML (OR = 2.69), high-risk (OR = 3.34), albumin < 3.5 g/dl (OR = 5) and platelets < 20 × 103/uL (OR = 2.71) with a 60-day ED.

CONCLUSION

None of the interval-delays were associated with an ED. Intervals seemed to be longer in patients without an ED, except for the TI, probably because of "the waiting time paradox." Aggressive manifestations of disease may lead to shorter diagnostic intervals, but increased mortality.

Awareness of cancer among adolescents: A study of nine focus groups in Aotearoa New Zealand

ISSUE ADDRESSED

One third of cancers are potentially preventable by modifying key risk factors that arise during adolescence. To help inform prevention efforts, we investigated adolescents' understanding of cancer risk factors, symptoms and signs and barriers to help-seeking.

METHODS

Nine focus groups were conducted with purposefully sampled, binary-gendered friendship groups of 12 to 17-year-olds. Interviews were analysed using a qualitative descriptive method based on the topic schedule, transcripts and field notes.

RESULTS

Behavioural, genetic and environmental factors were commonly explored as risk factors. Most cancer symptoms identified focused on physical indicators, such as lumps and skin appearance. Facilitators and barriers to good health choices involved both external and internal factors: education, affordability, attitudes and the social environment. Most participants indicated they would talk to trusted friends and family members about health issues, but only when the condition became 'serious'. The most common source of health information was the internet.

CONCLUSIONS

Adolescents have a good understanding of behavioural risk factors, but poor knowledge of some key cancer symptoms. A support system was recognised to be a substantive factor in dealing with health issues, as were youth-focused health services. Understanding of the preventability of many cancers was not widespread with participants. SO WHAT?: The results emphasise a requirement for appropriate, affordable and accessible youth-focused health services. There is a need for age- and culturally appropriate interventions that improve knowledge of cancer symptoms. Immunisation against the viruses implicated in cervical cancer is one example of a clinical cancer prevention intervention in adolescence.

Identifying early symptoms associated with a diagnosis of childhood, adolescent and young adult cancers: a population-based nested case-control study

BACKGROUND

Childhood, teenage and young adult (CTYA, 0-24 years) cancers are rare and diverse, making timely diagnosis challenging. We aim to explore symptoms and symptom combinations associated with a subsequent cancer diagnosis and to establish their timeframe.

METHODS

Using the QResearch Database, we carried out a matched nested case-control study. Associations between pre-specified symptoms encountered in primary care and a subsequent diagnosis of any cancer were explored using conditional logistic regression. Median diagnostic intervals were used to split symptoms into "late" and "early" timeframes to identify relevant early symptoms.

RESULTS

3186 cases and 50,576 controls were identified from a cohort of 3,424,771 CTYA. We identified 12 novel associations, of which hemiparesis [OR 90.9 (95%CI 24.7-335.1), PPV = 1.6%], testicular swelling [OR 186.7 (95%CI 86.1-404.8), PPV = 2.4%] and organomegaly [OR 221.6 (95%CI 28.3-1735.9), PPV = 5.4%] had significant positive predictive values (PPV). Limb pain, a known marker of serious illness in children, was a recurrent early symptom across cancer subtypes. Similar clinical presentations were observed across childhood and TYA cancers.

DISCUSSION

Using the largest cohort to date, we provide novel information on the time-varying predictive utility of symptoms in the diagnosis of CTYA cancers. Our findings will help to raise clinical and public awareness of symptoms, stratify those at higher-risk and ultimately aid earlier diagnosis.

Understanding Diagnosis Delay in Children With Cancer: Evidence From a Single Institution in Jordan

BACKGROUND

This study aimed to evaluate the factors associated with diagnosis delay in children with cancer who are treated at a single institution, which caters to most children with cancer in Jordan.

METHODS

This was a cross-sectional study with a retrospective chart review of selected patients who were diagnosed from August 2018 to December 2021. Data on patient and household characteristics, medical history, and diagnostic delay were collected through structured interviews. Univariable and multivariable linear and logistic regression models were used to identify predictors of delay.

RESULTS

The study included a cohort of 202 patient-caregiver pairs, with a median total delay from symptom onset to treatment initiation of 47 days (interquartile range [IQR], 21 to 114 d). Notably, 86% of families pursued medical consultation within a month of recognizing symptoms. A regression model revealed CNS tumors as a significant independent predictor of increased total delay ( P =0.002), with affected patients experiencing a median delay markedly longer than those with other cancer types. In addition, older patient age predicted longer total delay ( P =0.025). Symptomatology played a pivotal role in the timeliness of the diagnosis; specifically, visible symptoms such as pallor, bruises, and jaundice were associated with more expedient medical attention, with significantly shorter delays ( P values: 0.011, <0.001, and 0.045, respectively). Furthermore, our investigation disclosed a notable variance in symptom prevalence across different cancer categories, elucidating the complex relationship between clinical presentation and diagnostic timelines.

CONCLUSIONS

This study highlights the importance of the diagnosis of CNS tumors, patient age, and symptoms in predicting diagnosis delay in pediatric oncology patients. These findings can inform interventions to reduce delays in diagnosis and improve outcomes for these patients. These insights are crucial for developing targeted educational programs aimed at healthcare professionals and families to accelerate the recognition and referral of pediatric cancer cases.

Delayed diagnosis of ocular graft-versus-host disease after allogeneic hematopoietic stem cell transplantation

PURPOSE

To investigate the delayed diagnosis of chronic ocular graft-versus-host disease (coGVHD) after allogeneic hematopoietic stem cell transplantation (alloHCT), and further analyze potential confounding factors.

METHODS

This cross-sectional study included 118 patients newly diagnosed as coGVHD after alloHCT at Zhongshan Ophthalmic Center, Sun Yat-sen University. All participants finished the flow path of medical history taking, detailed ophthalmological examination and questionnaire-based survey. coGVHD was diagnosed and graded by International Chronic Ocular GVHD Consensus Group (ICOGCG) criteria. Lag time of diagnosis was defined as interval between noting of ocular symptoms and confirmed diagnosis of coGVHD (TN-D). We further compared the clinical parameters between groups categorized by the median TN-D as medium and long delay groups.

RESULTS

The median TN-D was 6.3 [IQR 2.8-14.5] months. Most coGVHD patients underwent delayed diagnosis of coGVHD longer than 3 months (70 %, 83 of 118), with 90 of 118 diagnosed as severe coGVHD (76 %). The long delay group exhibited higher ICOGCG scores (10 [IQR 9-10.5] vs. 9 [IQR 8-10], P = 0.039) and more pronounced ocular signs, including conjunctival injection, meibomian gland loss, fibrotic tarsal conjunctiva, symblepharon, and corneal complications (all P < 0.05). Delayed diagnosis was strikingly correlated with seeking ophthalmic medical care twice or more prior to diagnosis (adjusted OR = 5.42, 95%CI: 1.40-21.06, P = 0.015) and accurate knowledge of ocular discomfort symptoms in coGVHD (adjusted OR = 0.29, 95%CI: 0.08-1.00, P = 0.050).

CONCLUSIONS

Delayed diagnosis of coGVHD, associated with disease severity, was common among alloHCT recipients in southern China. Improving patient education and the awareness of ophthalmologists may facilitate early diagnosis of coGVHD.

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.

Optimal cut-off values and diagnostic significance of clinical laboratory indicators in newly diagnosed multiple myeloma

OBJECTIVE

This study aims to identify clinical laboratory parameters for the diagnosis of newly diagnosed multiple myeloma (NDMM), establish optimal cutoffs for early screening, and develop a diagnostic model for precise diagnosis.

METHODS

The study conducted a retrospective analysis of 279 NDMM patients and 553 healthy subjects at Zhejiang Province People's Hospital between January 2008 and June 2023. Multifactor LR was employed to explore clinical laboratory indicators with diagnostic value for NDMM, determine optimal cutoff values and contract a diagnostic model. The diagnostic efficacy and clinical utility were evaluated using receiver operating characteristic curves (ROC), sensitivity, specificity, and other indicators.

RESULTS

Multifactor analysis revealed that hemoglobin (Hb), albumin (Alb), and platelet distribution width (PDW) were significant diagnostic factors for NDMM. Optimal cutoff values for Hb, Alb, and PDW in MM diagnosis were determined, and the results showed a significant increase in the probability of NDMM diagnosis when Alb was below 39.3 g/L, Hb was below 11.6 g/dL, and PDW was below 14.1 fL. The diagnostic model constructed from the development cohort demonstrated a high area under the ROC curve of 0.960 (95% CI 0.942-0.978) and exhibited good sensitivity (0.860), specificity (0.957). The area under the curve (AUC) value of the diagnostic model in the external validation cohort was 0.979, confirming its good diagnostic efficacy and generalization.

CONCLUSIONS

The optimal cutoff values for Hb, Alb, and PDW and the diagnostic model designed in the study provided good accuracy and sensitivity for the initial screening and diagnosis of NDMM.

Investigations and referral for suspected gastric cancer by primary care physicians: a cross-sectional study in Southeastern China

BACKGROUND

Early recognition and accurate diagnosis are particularly important in the context of gastric cancer. This study mainly aimed to investigate primary care physicians' (PCPs') clinical behaviour and their readiness to consider investigation or referral for symptoms possibly indicative of gastric cancer.

DESIGN

Cross-sectional study.

SETTING

A self-administered online survey was carried out in five selected cities in the Fujian province of China between February 2022 and May 2022.

PARTICIPANT

PCPs working in the departments, such as Internal Gastroenterology and Hepatology, General Internal Medicine, Internal Medical Oncology Gastrointestinal Surgery or other clinical departments, have the chance to diagnose or treat patients with suspected gastric cancer.

MAIN OUTCOME MEASURES

Percentage of PCPs identifying gastric cancer patients either by undertaking an endoscopy at the primary hospital or by referring patients to an upper-level hospital.

RESULTS

A total of 1210 complete responses were received. Nearly half of responding PCPs (46.4%) only had less than 5 years of clinical experience, and the majority worked in suburban or rural regions (64.4%). Direct access to blood tests for cancer diagnosis (77.9%), X-ray (77.2%), CT (55.7%), ultrasound (85.3%), upper gastrointestinal endoscopy (54.4%) and colonoscopy (51.9%) was common. Of the respondents, 85.5% reported that they could get specialist advice for a suspected cancer patient within 48 hours in terms of investigations and 84.0% in terms of referral. Patients' waiting time to either conduct a test or have a result was mostly less than 1 week. In patients indicative of gastric cancer, a total of 1148 (94.8%) physicians were ready to investigate cancer either by sending patients to an endoscopy test (49.7%) or referring them to an upper-level hospital (45.1%).

CONCLUSIONS

Findings indicate that PCPs in five selected cities of Southeastern China have wide and rapid access to diagnostic tests and specialist advice. Furthermore, PCPs in this region seem to have a high level of readiness to consider investigation or referral for symptoms possibly indicative of gastric cancer.

Risk Factors for Suboptimal Colon Cancer Diagnosis and Management at a Safety-Net Hospital System

INTRODUCTION

Colon cancer (CC) is the second leading cause of cancer-related deaths in the United States. Quality measures have been introduced by the American Gastroenterological Association and Commission on Cancer for optimal management of CC. In this study, we sought to identify factors that may hinder the timely diagnosis and treatment of CC at a safety-net hospital system.

METHODS

Retrospective chart review was performed for patients aged ≥18 y diagnosed with CC from 2018 to 2021. Primary outcomes were time from positive fecal immunochemical test to colonoscopy, time from diagnosis to surgery, and time from diagnosis to adjuvant chemotherapy. Secondary end points were demographic characteristics associated with suboptimal outcomes in any of the above measures.

RESULTS

One hundred ninety patients were diagnosed with nonmetastatic CC. The majority were Hispanic and non-English-speaking. 74.1% of patients with a positive fecal immunochemical test received a colonoscopy within 180 d. 59.6% of nonemergent cases received surgery within 60 d of diagnosis. 77% of those eligible received adjuvant chemotherapy within 120 d of diagnosis. No clinically significant demographic factor was associated with delay in colonoscopy, surgery, or adjuvant chemotherapy. Most frequent cause of delay in surgery (38.0%) was optimization of comorbidities. Most frequent cause of delay in adjuvant chemotherapy (71.4%) was delay in surgery itself.

CONCLUSIONS

No clinically significant demographic factor was associated with experiencing delays in diagnostic colonoscopy, surgery, or adjuvant chemotherapy.

Time to Diagnosis and Treatment for Ovarian Cancer and Associations with Outcomes: A Systematic Review

Background: Ovarian cancer is commonly diagnosed symptomatically at an advanced stage. Better survival for early disease suggests improving diagnostic pathways may increase survival. This study examines literature assessing diagnostic intervals and their association with clinical and psychological outcomes. Methods: Medline, EMBASE, and EmCare databases were searched for studies including quantitative measures of at least one interval, published between January 1, 2000 and August 9, 2022. Interval measures and associations (interval, outcomes, analytic strategy) were synthesized. Risk of bias of association studies was assessed using the Aarhus Checklist and ROBINS-E tool. Results: In total, 65 papers (20 association studies) were included and 26 unique intervals were identified. Interval estimates varied widely and were impacted by summary statistic used (mean or median) and group focused on. Of Aarhus-defined intervals, patient (symptom to presentation, n = 23; range [median]: 7-168 days) and diagnostic (presentation to diagnosis, n = 22; range [median]: 7-270 days) were most common. Nineteen association studies examined survival or stage outcomes with most, including five low risk-of-bias studies, finding no association. Conclusions: Studies reporting intervals for ovarian cancer diagnosis are limited by inconsistent definitions and reporting. Greater utilization of the Aarhus statement to define intervals and appropriate analytic methods is needed to strengthen findings from future studies.

Dissecting the Prediagnostic Journey to Identify Opportunities for Early Detection of Esophageal Cancer: Findings From a High-Risk Area in Rural China

PURPOSE

Survival from esophageal cancer (EC) is poor, partly reflecting the delay in diagnosis. To inform the potential measures for downstaging the disease, we estimated diagnosis delay, that is, the length of interval from symptom-to-diagnosis (STD), and investigated its correlates among patients with EC in a high-risk resource-limited rural area in China.

METHODS

Patients newly diagnosed with EC (N = 411) were recruited in a secondary hospital in Henan province in China between August 1, 2018, and October 21, 2020. A face-to-face structured questionnaire was used to collect patient-level and health-seeking data from patients and/or proxies. Association between the length of STD interval and stage at diagnosis was examined using logistic regression. Correlates of the length of the STD interval were identified using negative binomial regression.

RESULTS

The median STD interval was 61 (IQR, 24-155) days, with the time from symptom onset to first health care contact representing 90.1% (IQR, 7.8%-100%) of its length. The odds of being diagnosed at stages III-IV increased by 3% (age- and sex-adjusted odds ratio, 1.03 [95% CI, 0.99 to 1.08]) for every 2-month increase in the STD interval. Higher awareness of EC risk factors was associated with shorter STD intervals (incidence rate ratio [95% CI] for awareness score ≥2 v ≤0: 0.65 [0.46 to 0.93]), whereas patients who first visited secondary or tertiary/cancer hospitals had much longer STD intervals than those who first visited a primary health care facility (1.69 [1.19 to 2.40]; 2.22 [1.24 to 3.97]).

CONCLUSION

The median length of the STD interval was 2 months, but with considerable interindividual variability. Improving EC awareness, coupled with effective referral pathways, may promote timely diagnosis of this disease.

Wait times and breast cancer survival: a population-based retrospective cohort study using CanIMPACT data

PURPOSE

The time from breast cancer surgery to chemotherapy has been shown to affect survival outcomes; however, the effect of time from first breast cancer-related healthcare contact to first cancer specialist consultation, or the time from first breast cancer-related healthcare contact to adjuvant chemotherapy on survival has not been well explored. We aimed to determine whether various wait times along the breast cancer treatment pathway (contact-to-consultation, contact-to-chemotherapy, surgery-to-chemotherapy) were associated with overall survival in women within the Canadian province of Ontario.

METHODS

We performed a population-based retrospective cohort study of women diagnosed with stage I-III breast cancer in Ontario between 2007 and 2011 who received surgery and adjuvant chemotherapy. This was the Ontario cohort of a larger, nationwide study (the Canadian Team to improve Community-Based Cancer Care along the Continuum - CanIMPACT). We used Cox-proportional hazards regression to determine the association between the contact-to-consultation, contact-to-chemotherapy, and surgery-to-chemotherapy intervals and overall survival while adjusting for cancer stage, age, comorbidity, neighborhood income, immigration status, surgery type, and method of cancer detection.

RESULTS

Among 12,782 breast cancer patients, longer surgery-to-chemotherapy intervals (HR 1.13, 95% CI 1.03-1.18 per 30-day increase), but not the contact-to-consultation (HR 0.979, 95% CI 0.95-1.01 per 30-day increase), nor the more comprehensive contact-to-chemotherapy intervals (HR 1.00, 95% CI 0.98-1.02 per 30-day increase) were associated with decreased survival in our adjusted analyses.

CONCLUSION

Our findings emphasize the prognostic importance of a shorter surgery-to-chemotherapy interval, whereas the contact-to-consultation and contact-to-chemotherapy intervals have less impact on survival outcomes.

Treatment delays for cancer patients in Sub-Saharan Africa: South Africa as a microcosm

Purpose

Delays in initiating cancer treatment time to treatment initiation (TTI) can negatively impact patient outcomes. This study aimed to quantify the association between TTI and survival in breast, cervical and prostate cancer patients at Inkosi Albert Luthuli Central Hospital (IALCH) in KwaZulu-Natal, South Africa, as a microcosm of Sub-Saharan Africa (SSA).

Methods

We analyzed electronic medical records of patients diagnosed with breast, cervical or prostate cancer at IALCH between 2010 and 2020. Median TTI was calculated for different treatment modalities. To assess the link between treatment delay and mortality, we employed a Cox proportional hazards model to estimate hazard ratios (HRs) and 95% confidence intervals (CIs), treating breast cancer and patients over 40 as competing events. Additionally, Kruskal-Wallis one-way analysis and linear regression were used to compare TTI across racial groups.

Results

The study included patients with breast (44%), cervical (44%) and prostate cancer (12%). Mean age at diagnosis was 62.6, 56.6 and 73.0 years, respectively. Breast cancer patients experienced the longest delays for mastectomy (median 18.4 weeks), followed by prostate cancer patients waiting for radiotherapy (median 16.6 weeks). Significantly longer TTI for radiotherapy was observed in patients younger than 40 with cervical (HR = 2.30, 95% CI: 2.16-2.44, p < 0.001) or prostate cancer (HR = 1.42, 95% CI: 1.03-1.95, p = 0.033) compared to older breast cancer patients. Similar trends were seen for younger patients with cervical cancer receiving chemotherapy. Notably, all racial groups exhibited substantial delays in initiating treatment for all three cancers (breast p < 0.001, prostate p = 0.004 and cervical cancer p < 0.001).

Conclusion

This study identified significant delays in treatment initiation (TTI) for breast, prostate and cervical cancer patients at Inkosi Albert Luthuli Central Hospital (IALCH) in South Africa. These delays were concerning, particularly for younger patients and individuals across all racial backgrounds. Delays in treatment initiation have been linked to increased mortality risk in other studies, highlighting the urgency of addressing this issue. Furthermore, this study serves as a valuable model for future research throughout SSA to collectively address the challenges of treatment delays and improve cancer care for the region.

Examining inequities associated with incarceration among breast cancer patients

INTRODUCTION

Breast cancer treatment patterns and quality of care among patients experiencing incarceration are underexplored. This study examined associations between incarceration and breast cancer disease and treatment characteristics.

METHODS

This retrospective analysis was conducted at a tertiary center in the Southeastern United States that serves as the state's safety-net hospital and primary referral site for the state's prisons. All patients ≥18 years diagnosed with breast cancer between 4/14/2014-12/30/2020 were included. Incarceration status was determined through electronic health record review. Linear regression was used to estimate the association of incarceration with time to treatment. Unadjusted overall survival (OS) was estimated using the Kaplan-Meier method with log-rank tests to compare groups.

RESULTS

Of the 4329 patients included, 30 (0.7%) were incarcerated at the time of diagnosis or treatment (DI) and 4299 (99.3%) had no incarceration history (NI). Compared to patients who were NI, patients who were DI were younger (p < 0.001), more likely to be unmarried (p < 0.001), and more likely to have family history of breast cancer (p = 0.02). Patients who were DI had an increased time from diagnosis to neoadjuvant chemotherapy (+47.2 days on average, 95% CI 3.9-90.5, p = 0.03) and from diagnosis to surgery (+20 days on average, 95% CI 6.5-33.5, p = 0.02) compared to NI patients. No difference in OS was observed (log-rank p = 0.70).

CONCLUSIONS

Patients who are incarcerated experienced significant delays in breast cancer care. While no differences in mortality were appreciated, these findings are concerning, as they indicate poorer care coordination for patients who are incarcerated. Further research is necessary to understand the full scope of these disparities and elucidate factors that contribute to them.

Exploring Whether and How People Experiencing High Deprivation Access Diagnostic Services: A Qualitative Systematic Review

INTRODUCTION

To contribute to addressing diagnostic health inequalities in the United Kingdom, this review aimed to investigate determinants of diagnostic service use amongst people experiencing high deprivation in the United Kingdom.

METHODS

A systematic review was conducted using three databases (EBSCO, Web of Science and SCOPUS) to search studies pertaining to diagnostic service use amongst people experiencing high deprivation. Search terms related to diagnostics, barriers and facilitators to access and deprivation. Articles were included if they discussed facilitators and/or barriers to diagnostic service access, contained participants' direct perspectives and focussed on individuals experiencing high deprivation in the United Kingdom. Articles were excluded if the full text was unretrievable, only abstracts were available, the research did not focus on adults experiencing high deprivation in the United Kingdom, those not including participants' direct perspectives (e.g., quantitative studies) and papers unavailable in English.

RESULTS

Of 14,717 initial papers, 18 were included in the final review. Determinants were grouped into three themes (Beliefs and Behaviours, Emotional and Psychological Factors and Practical Factors), made up of 15 sub-themes. These were mapped to a conceptual model, which illustrates that Beliefs and Behaviours interact with Emotional and Psychological Factors to influence Motivation to access diagnostic services. Motivation then influences and is influenced by Practical Factors, resulting in a Decision to Access or Not. This decision influences Beliefs and Behaviours and/or Emotional and Psychological Factors such that the cycle begins again.

CONCLUSION

Decision-making regarding diagnostic service use for people experiencing high deprivation in the United Kingdom is complex. The conceptual model illustrates this complexity, as well as the mediative, interactive and iterative nature of the process. The model should be applied in policy and practice to enable understanding of the factors influencing access to diagnostic services and to design interventions that address identified determinants.

PATIENT OR PUBLIC CONTRIBUTION

Consulting lived experience experts was imperative in understanding whether and how the existing literature captures the lived experience of those experiencing high deprivation in South England. The model was presented to lived experience experts, who corroborated findings, highlighted significant factors for them and introduced issues that were not identified in the review.

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

BACKGROUND

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

AIM

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

DESIGN AND SETTING

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

METHOD

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

RESULTS

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

CONCLUSION

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

Early Symptom Patterns by Tumor Laterality, Age at Onset, Stage, and Symptom-to-Treatment Initiation in Patients with Colorectal Cancer

BACKGROUND

In Indonesia incidence of colorectal cancer (CRC) remains high. Information about early symptoms that can offer clinicians insights for timely diagnosis, prompt referral and quick treatment decisions is very limited. This study aims to examine the pattern of CRC early symptoms and its association with tumor laterality, age at onset, metastatic status, and symptom-to-treatment initiation (STI) duration and delay.

METHOD

This cross-sectional study recruits 258 patients diagnosed with CRC between November 2022 and October 2023 from two distinct study databases. Patient baseline characteristics were also obtained from medical records and through interviews at baseline. Symptom-to-treatment initiation (STI) duration was defined as the number of days between the date of the symptom's onset and the date of the first treatment's initiation. Relative risk estimation for metastatic disease and the STI delay, based on tumor laterality and the age at onset group, were estimated using a log-binomial regression for each early symptom.

RESULT

Experiencing abdominal mass as an early symptom is significantly associated with metastatic disease, specifically in right-sided CRC cases (relative risk/RR=2.08, 95% confidence interval/CI 1.29-3.37, p=0.003). In all study subjects, the median STI duration was 182 days (2-5,082 days), with more than half of the subjects experiencing an STI delay of >180 days. Experiencing rectal mass as an early symptom is significantly associated with a higher risk of STI delay >180 days in early onset CRC (RR=1.97, 95% CI 1.27-3.06, p=0.003) and left sided-CRC cases (RR=1.54, 95% CI 1.13-2.08, p=0.005). The non-specific early symptom of weight loss is associated with a higher risk of STI delay >180 days in right-sided CRC cases (RR=1.73, 95% CI 1.06-2.84, p=0.029).

CONCLUSION

The findings underlined the importance of maintaining a high clinical suspicion, particularly in patients with rectal masses and unexplained weight loss, as they might experience STI delay.

Racial implications of time to surgery in disparities in thyroid cancer survival

INTRODUCTION

The influence of time to surgery on racial/ethnic disparities in papillary thyroid carcinoma (PTC) survival remains unstudied.

MATERIALS AND METHODS

The National Cancer Database (2004-2017) was queried for patients with localized PTC. Survival data was compared by time to surgery, patient demographics, and multivariable Cox regression was performed.

RESULTS

Of 126,708 patients included, 5% were Black, 10% Hispanic. Of all patients, 85% had no comorbidities. Non-Hispanic White (NHW) patients had a shorter median time to surgery than Black and Hispanic patients (36 vs. 43 vs. 42 days, respectively p ​< ​0.001). In multivariable analysis, longer time to surgery (>90 days vs ​< ​30 days) and Black race vs NHW, were associated with worse survival (HR: 1.56, (95%CI, 1.43-1.70), p ​< ​0.001 and HR: 1.21, (1.08-1.36), p ​= ​0.001), respectively.

CONCLUSION

Delaying surgery for thyroid cancer is associated with worse survival. However, independent of time to surgery and other confounders, there remains a disparity as black patients have poorer outcomes.

Self-Report of Changes in Cognitive-Communication Function and Social Engagement Among Adults With Cancer-Related Cognitive Impairment

PURPOSE

This study aimed to examine the prevalence of cognitive-communication deficits in adult cancer survivors who reported experiencing cancer-related cognitive impairment (CRCI). The study also aimed to determine how these problems impact their ability to engage socially and find satisfaction in their social roles.

METHOD

This study employed a cross-sectional survey to collect data from adult cancer survivors. The survey included questions on demographic characteristics, self-perceived cognitive-communication abilities, social engagement, and satisfaction with social participation. Data analysis included descriptive statistics, Spearman rank-order correlation, Mann-Whitney U tests, and Kruskal-Wallis H tests.

RESULTS

Of 172 participants, 78% completed the survey, with 109 self-reporting CRCI. The participants predominantly had breast cancer, and most were diagnosed with Stage II cancers. The results indicated self-perceived impairment in various cognitive-communication domains, with functional daily communication being the most affected. Participants reported more difficulty participating in social roles and activities than their overall satisfaction with social participation. This study explored the relationships between cognitive-communication scores and social engagement, considering variables such as education, cancer type, stage, age, and treatment.

CONCLUSIONS

This study underscores the multidimensional nature of CRCI, emphasizing the importance of addressing both cognitive-communication and social aspects in interventions and support services. It highlights the clinical implications for speech-language pathology, suggesting a potential role in identifying and addressing cognitive-communication deficits. Future research needs are discussed.

Impact of treatment delays on future survival outcomes in non-surgical patients with esophageal cancer in Shandong Province, China

The treatment process of tumors in surgical patients is typically prompt and efficient, whereas non-surgical patients are more prone to treatment delay due to various factors. However, the relationship between treatment delay and survival outcomes in non-surgical Esophageal cancer (EC) patients has received limited study. This study aims to evaluate the impact of waiting time from diagnose to treatment on survival outcomes among non-surgical EC patients in Shandong Province, China. Over a 20-year follow-up period, a total of 12,911 patients diagnosed with EC and not receiving surgical intervention were identified from 2000 to 2020. The Kaplan-Meier methodology was employed to determine overall survival (OS) and cancer-specific survival (CSS). Univariate and multivariate Cox regression analyses were performed to evaluate the impact of treatment delays on future outcomes. The nonlinear association between waiting time and survival outcomes was investigated using restricted cubic spline (RCS) functions. The average delay in initiating EC treatment from the initial medical consultation for symptoms of EC was 1.18 months (95%CI=1.16-1.20). Patients with a long delay (≥3 months) in treatment demonstrated significantly lower rates of 1-, 3-, and 5-year OS and CSS compared to those with a brief delay in treatment initiation. A long delay in EC treatment independently associated with an increased risk of mortality from all causes and cancer. The association between waiting time and both all-cause and cause-specific mortality illustrated a pronounced J-shaped pattern. The prolong delay in treatment initiation significantly impacts the OS and CSS outcomes for non-surgical EC patients. Timely administration of treatment has the potential to enhance survival outcomes in patients with EC who are ineligible for surgery, including those in advanced stages without surgical options available.

Patient perspectives on cancer care during COVID-19: A qualitative study

PURPOSE

The COVID-19 pandemic posed unique challenges to cancer-related care as health systems balanced competing risks of timely delivery of care and minimizing exposure to infection in a high-risk, immunocompromised patient population. This study aimed to better understand how pandemic-related factors affected the patient experience of cancer care during this time.

METHODS

We conducted fifteen semi-structured interviews with adults from rural counties in Maryland who were diagnosed with and/or actively treated for cancer at the TidalHealth healthcare network between January 2020 and October 2022.

RESULTS

Interviews from fifteen participants were analyzed. Two major themes emerged including COVID Impact on Care, and COVID Impact on Mental Health. Subthemes under COVID Impact on Care include Staffing Shortages, Hospital Regulations, Visitation, Importance of Advocacy, and Telehealth Utilization, and subthemes under COVID Impact on Mental Health include Loneliness, Support Networks, and Perceptions of COVID and Personal Protection. Overall, participants described positive care experiences despite notable delays, disruptions to continuity of care, difficult transitions to telemedicine, visitation policies that limited patient support, increased mental health struggles related to social distancing measures, and greater desire for patient advocacy.

CONCLUSION

Our findings reveal significant impacts of the COVID-19 pandemic on experiences of cancer treatment and survivorship in a more vulnerable, rural patient population with lower healthcare access and income level. Our findings suggest areas for targeted interventions to limit disruptions to quality care in future public health emergencies.

One or many labels? a longitudinal qualitative study of patients' journey to diagnosis at a specialist NHS Postural Tachycardia Syndrome (PoTS) clinic

OBJECTIVES

Postural Tachycardia Syndrome (PoTS) is a poorly understood syndrome of multiple disabling symptoms. This study explored the process of seeking a diagnosis of PoTS. Analysis focused on changes before and after participants' first appointment with a national PoTS clinic, and explored whether a diagnosis is beneficial in the context of multiple co-occurring conditions and an absence of licenced treatments.

DESIGN

A longitudinal, qualitative study.

METHODS

Participants (n = 15) in this nested qualitative study were recruited from a larger study of people who had been newly referred to a National specialist NHS Cardiology PoTS service. Semi-structured interviews were conducted remotely before, and 6 months after their first appointment with the clinic. Data was analysed longitudinally and inductively using Reflexive Thematic Analysis.

RESULTS

Three overarching themes were identified: "Slowly moving forward and finding positive gains", "Needing more pieces of the puzzle to see the bigger picture", and "The value and impact of investigations". Findings suggested that not much had changed in the 6 months between interviews. Participants were moving forward in terms of diagnoses, treatment and adjustment following their appointment, but many were still seeking further clarity and possible diagnoses. Investigations, appointments, and new-found problems, continued to have a substantial impact over time.

CONCLUSIONS

The journey to diagnosis for patients with suspected PoTS appeared to promote acceptance of self, and of limitations posed by symptoms. However, many participants continued their search for an explanation for every symptom experience, and this may become increasingly complex, the more labels that have been acquired. Lack of clarity contributed to ongoing difficulties for this patient group alongside fraught relations with health care professionals (HCPs). A more coherent, integrated approach which is communicated clearly to patients is recommended.

French national survey on breast cancer care: caregiver and patient views

PURPOSE

To improve the quality of care for patients with breast cancer, an analysis of the health-care pathway, considering feedback from both health-care practitioners (HCPs) and patients, is needed.

METHODS

Between 2020 and 2022, we conducted a survey at French breast cancer centers and analyzed information from questionnaires completed by HCPs and patients. We collected information on center organization, diagnostic processes, treatment decisions and modalities, supportive care, patient advocacy groups, and work issues.

RESULTS

Twenty-three breast cancer centers were included and questionnaires completed by 247 HCPs and 249 patients were analyzed. The centers closely followed the legal French framework for cancer treatments, which includes formal diagnostic announcements, multidisciplinary tumor boards, personalized treatment summaries, and supportive care access. HCPs and patients were satisfied with the time to diagnosis (≤ 2 weeks as evaluated by 75% of patients), time to surgery (mean 61 days), time between surgery and chemotherapy (mean 47 days), and time between surgery and radiotherapy (mean 81 days). Fertility preservation counseling for women under 40 years of age was systematically offered by 67% of the HCPs. The majority (67%) of the patients indicated that they had received a personalized treatment summary; the topics discussed included treatments (92%), tumor characteristics (84%), care pathways (79%), supportive care (52%), and breast reconstruction (33%). Among HCPs, 44% stated that reconstructive surgery was offered to all eligible patients and 57% and 45% indicated coordination between centers and primary care physicians for adverse effects management and access to supportive care should be improved, for chemotherapy and radiotherapy, respectively. Regarding patient advocacy groups, 34% of HCPs did not know whether patients had contact and only 23% of patients declared that they had such contact. For one-third of working patients, work issues were not discussed. Twenty-eight percent of patients claimed that they had faced difficulties for supportive care access. Among HCPs, 13% stated that a formal personalized survivorship treatment program was administered to almost all patients and 37% almost never introduced the program to their patients. Compliance to oral treatments was considered very good for 75-100% of patients by 62% of HCPs.

CONCLUSIONS

This study provides an updated analysis of breast cancer care pathways in France. Overall, the initial processes of diagnosis, announcement, and treatment were swift and were in agreement with the best care standards. No barriers to accessing care were identified. Based on the study findings, we proposed several strategies to improve the quality of care for patients in supportive care, coordination with primary care physicians, reconstructive surgery, and fertility preservation access.

Estimating surgery, radiotherapy and systemic anti-cancer therapy treatment costs for cancer patients by stage at diagnosis

BACKGROUND

The increasing burden of cancer has economic implications for the healthcare system in England. However, there is limited evidence on the cost of cancer treatment. We calculated the costs of initial cancer treatment (resection, radiotherapy, systemic anti-cancer therapy [SACT]) based on stage at diagnosis.

METHODS

Data from England's National Cancer Registration Dataset were matched to English Hospital, Radiotherapy and SACT data for breast, lung, prostate, colon and rectal cancers diagnosed between 2016 and 2018. Treatment data were matched to National Schedule of Reference Costs data to calculate the cost of each treatment event.

RESULTS

Breast, colon and rectal cancers treated with resection, radiotherapy or SACT had increasing costs with later stage at diagnosis; costs for lung and prostate cancers were lower at stages 1 and 4 compared to stages 2 and 3. In general, surgery and SACT were the most expensive treatments. Radiotherapy and SACT costs showed little change across stages 1-3; radiotherapy costs decreased in stage 4, while SACT costs increased.

CONCLUSIONS

This analysis estimates initial treatment costs by stage based on observed data. Future research can build on this to provide more comprehensive costings associated with cancer; this is important for future planning of cancer services.

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.

A Scoping Review of Compassion Fatigue Among Oncology Nurses Caring for Adult Patients

BACKGROUND

Oncology nurses have frequent contact with oncology patients during their cancer journey. This long-term, recurrent contact can impact the health and well-being of the nurse through the development of compassion fatigue (CF).

OBJECTIVES

To identify what contributes to CF and what individual, interpersonal, and organizational factors mitigate CF among oncology nurses caring for adult patients.

METHODS

A scoping review framework by Arksey and O'Malley guided this review. Electronic databases were searched for relevant studies. A blinded screening process was undertaken by the authors using the following inclusion criteria: English language published from January 2011 to December 2021, primary research peer-reviewed studies, and focusing on CF within oncology nurses caring for adult patients in any practice setting.

RESULTS

Nineteen studies (21 articles) were identified. The review found nurses' personal beliefs around nursing care being provided, and personality traits of psychological inflexibility, neuroticism, passive coping, and avoidance contributed to CF. Workplace conflict and lack of a healthy work-life balance also contributed to CF. However, nurses' personal resilience, ability to positively reflect upon their work, a supportive team environment, and continuing education were found to mitigate CF.

CONCLUSIONS

Levels of CF vary among oncology nurses caring for adult patients. Oncology nurses may benefit from personal and organizational resources aimed at improving oncology nurses' professional quality of life while decreasing CF.

IMPLICATIONS FOR PRACTICE

Consideration and future research of effective interventions are needed to sustain a future health workforce and mitigate CF among oncology nurses.

Multilevel contributors to racial and ethnic inequities in the resolution of abnormal mammography results

PURPOSE

Multiple ecological levels influence racial inequities in the completion of diagnostic testing after receiving abnormal mammography results (diagnostic resolution). Yet, few studies examine more than two ecological levels. We investigated the contributions of county, imaging facility, and patient characteristics on our primary and secondary outcomes, the achievement of diagnostic resolution by (1)Black women and Latinas, and (2) the entire sample. We hypothesized that women of color would be less likely to achieve resolution than their White counterparts, and this relationship would be mediated by imaging facility features and moderated by county characteristics.

METHODS

Records for 25,144 women with abnormal mammograms between 2011 and 2019 from the Carolina Mammography Registry were merged with publicly available county data. Diagnostic resolution was operationalized as the percentage of women achieving resolution within 60 days of receiving abnormal results and overall time to resolution and examined using mixed effects logistic regression and Cox proportional hazard models, respectively.

RESULTS

Women of color with abnormal screening mammograms were less likely to achieve resolution within 60 days compared with White women (OR 0.83, CI 0.78-0.89; OR 0.74, CI.60-0.91, respectively) and displayed longer resolution times (HR 0.87, CI 0.84-0.91; HR 0.78, CI 0.68-0.89). Residential segregation had a moderating effect, with Black women in more segregated counties being less likely to achieve resolution by 60 days but lost statistical significance after adjustment. No mediators were discovered.

CONCLUSION

More work is needed to understand how imaging center and community characteristics impact racial inequities in resolution and resolution in general.

Improving Care for Older Adults with Cancer in Canada: A Call to Action

Most patients diagnosed with and dying from cancer in Canada are older adults, with aging contributing to the large projected growth in cancer incidence. Older adults with cancer have unique needs, and on a global scale increasing efforts have been made to address recognized gaps in their cancer care. However, in Canada, geriatric oncology remains a new and developing field. There is increasing recognition of the value of geriatric oncology and there is a growing number of healthcare providers interested in developing the field. While there is an increasing number of dedicated programs in geriatric oncology, they remain limited overall. Developing novel methods to delivery geriatric care in the oncology setting and improving visibility is important. Formal incorporation of a geriatric oncology curriculum into training is critical to both improve knowledge and demonstrate its value to healthcare providers. Although a robust group of dedicated researchers exist, increased collaboration is needed to capitalize on existing expertise. Dedicated funding is critical to promoting clinical programs, research, and training new clinicians and leaders in the field. By addressing challenges and capitalizing on opportunities for improvement, Canada can better meet the unique needs of its aging population with cancer and ultimately improve their outcomes.

Plasma H3Cit-DNA Discriminates Between Cancer and Inflammation in a Cohort of Patients with Unspecific Cancer Symptoms

Cancer detection is challenging, especially in patients with unspecific cancer symptoms. Biomarkers could identify patients at high risk of cancer. Prior studies indicate that neutrophil extracellular traps (NETs) are associated with cancer, but also with autoimmune and infectious diseases. The objective of this prospective study was to investigate markers associated with NET formation (nucleosomal citrullinated histone 3 [H3Cit-DNA], cell free DNA [cfDNA] and neutrophil elastase [NE]), and c-reactive protein (CRP) in patients with unspecific cancer symptoms, such as fatigue, weight loss or radiological sign of malignancy without an apparent primary tumor, referred to the Diagnostic Center at Danderyd Hospital in Sweden. Blood samples were drawn on admission, before cancer diagnosis. Out of 475 patients, 160 (34%) were diagnosed with cancer, 56 (12%) with autoimmune disease, 32 (7%) with infectious disease, 71 (15%) with other diseases and 156 (33%) received no diagnosis. H3Cit-DNA, cfDNA, NE and CRP were significantly higher in patients with cancer compared to patients without cancer (p < 0.0001, p < 0.0001, p = 0.004, and p = 0.0002 respectively). H3Cit-DNA, but not cfDNA, NE or CRP, was significantly elevated in patients with cancer compared to patients with autoimmune disease (p = 0.0001). H3Cit-DNA, cfDNA, NE or CRP did not differ between cancer and infectious disease. In conclusion, H3Cit-DNA is elevated in patients diagnosed with cancer compared to non-cancer patients with the same symptomatology. Further studies should evaluate if H3Cit-DNA could aid in selecting patients that would benefit the most from a rapid cancer diagnostic work-up.