General practitioner referrals to one-stop clinics for symptoms that could be indicative of cancer: a systematic review of use and clinical outcomes

The effect of community diagnostic centres on volume and waiting time for diagnostic procedures in the UK

Many health care systems are looking to implement policies to improve productivity and accessibility of health care. In this paper we use data from the English National Health Service to evaluate the effect of introducing new "Community Diagnostic Centres" in 2021 which aim to increase volume, reduce waiting times, and increase accessibility to diagnostic procedures. Our results show an increase in volume of diagnostic procedures associated with the introduction of CDCs at local NHS organisations. We find some evidence the increase is driven by an increase in MRI scans in particular, and this result is larger for CDCs located in more deprived local areas. We find no effect on waiting times which may indicate some demand response to increased availability of tests.

One-Stop-Shop Cancer Screening Clinic: Acceptability Testing

Cancer screenings aid in the early detection of cancer and can help reduce cancer-related mortality. The current model of care for cancer screening is often siloed, based on the targeted cancer site. We tested the acceptability of a new model of care, called the One-Stop-Shop Cancer Screening Clinic, that centralizes cancer screenings and offers patients the option to complete all their recommended cancer screenings within one to two visits. We administered surveys to 59 community members and 26 healthcare providers to gather feedback about the One-Stop-Shop model of care. Both community members and providers identified potential benefits (e.g., decreased patient burden, increased completion of cancer screenings) and also potential challenges (e.g., challenges with workflow and timing of care) of the model of care. The results of the study support the acceptability of the model of care. Of the community members surveyed, 89.5% said, if offered, they would be interested in participating in the One-Stop-Shop Cancer Screening Clinic. Future studies are needed to formally evaluate the impact and cost effectiveness of the One-Stop-Shop Cancer Screening Clinic.

Diagnostic Biopsy for Small Renal Tumours: A Survey of Current European Practice

Background and objective

Renal tumour biopsy (RTB) can help in risk stratification of renal tumours with implications for management, but its utilisation varies. Our objective was to report current practice patterns, experiences, and perceptions of RTB and research gaps regarding RTB for small renal masses (SRMs).

Methods

Two web-based surveys, one for health care providers (HCPs) and one for patients, were distributed via the European Association of Urology Young Academic Urologist Renal Cancer Working Group and the European Society of Residents in Urology in January 2023.

Key findings and limitations

The HCP survey received 210 responses (response rate 51%) and the patient survey 54 responses (response rate 59%). A minority of HCPs offer RTB to >50% of patients (14%), while 48% offer it in <10% of cases. Most HCPs reported that RTB influences (61.5%) or sometimes influences (37.1%) management decisions. Patients were more likely to favour active treatment if RTB showed high-grade cancer and less likely to favour active treatment for benign histology. HCPs identified situations in which they would not favour RTB, such as cystic tumours and challenging anatomic locations. RTB availability (67%) and concerns about delays to treatment (43%) were barriers to offering RTB. Priority research gaps include a trial demonstrating that RTB leads to better clinical outcomes, and better evidence that benign/indolent tumours do not require active treatment.

Conclusions and clinical implications

Utilisation of RTB for SRMs in Europe is low, even though both HCPs and patients reported that RTB results can affect disease management. Improving timely access to RTB and generating evidence on outcomes associated with RTB use are priorities for the kidney cancer community.

Patient summary

A biopsy of a kidney mass can help patients and doctors make decisions on treatment, but our survey found that many patients in Europe are not offered this option. Better access to biopsy services is needed, as well as more research on what happens to patients after biopsy.

Analysis of the financial impact and efficiency of the One Stop Prostate Clinic: A same day prostate cancer diagnostic clinic in the Australian public health system

Background

Access to prostate cancer diagnostic clinics are challenging for rural men in Western Australia due to remoteness and long travel distances. The One Stop Prostate Clinic (OSPC) provided same day assessment and diagnosis for prostate cancer in a public tertiary hospital to reduce access barriers for rural men. The objective of this study was to determine the financial and resource utilisation impact of the OSPC compared to a usual care pathway (UCP).

Design and methods

Study design: Cost minimisation analysis of the OSPC model (assuming 100% new referrals) compared with a UCP, including impact on the Patient Assisted Transport Scheme (PATS) for rural men. An estimate of total cost comparison of OSPC and UCP pathways of outpatient and diagnostic costs was calculated based on journey mapping of attendance and follow up.

Methods

Prospective data collection between August 2011 and November 2017 of referral, attendance and follow up outcomes. Journey mapping to identify time from referral to diagnosis, number of outpatient appointment (OPA) and travel savings.

Results

A total of 1000 men attended - 466 (47%) rural and 534 (53%) metro. Mean time from referral to diagnosis was 57 days (rural) versus 63 (metro; p = 0.034)). The OSPC saved 543 travel episodes (distance of 1.5M km) and 658 OPA's. Total episode of care costs for the OSPC (100% new) pathway estimated as $2237.34, compared to $2847.00 for a UCP, generating savings of $609.66 per attendance ($609,658.22 overall).

Conclusion

The OSPC was more cost effective and efficient in comparison to a UCP.

Protocol for a feasibility study of a cancer symptom awareness campaign to support the rapid diagnostic centre referral pathway in a socioeconomically deprived area: Targeted Intensive Community-based campaign To Optimise Cancer awareness (TIC-TOC)

INTRODUCTION

Rapid diagnostic centres (RDCs) are being implemented across the UK to accelerate the assessment of vague suspected cancer symptoms. Targeted behavioural interventions are needed to augment RDCs that serve socioeconomically deprived populations who are disproportionately affected by cancer, have lower cancer symptom awareness and are less likely to seek help for cancer symptoms. The aim of this study is to assess the feasibility and acceptability of delivering and evaluating a community-based vague cancer symptom awareness intervention in an area of high socioeconomic deprivation.

METHODS AND ANALYSIS

Intervention materials and messages were coproduced with local stakeholders in Cwm Taf Morgannwg, Wales. Cancer champions will be trained to deliver intervention messages and distribute intervention materials using broadcast media (eg, local radio), printed media (eg, branded pharmacy bags, posters, leaflets), social media (eg, Facebook) and attending local community events. A cross-sectional questionnaire will include self-reported patient interval (time between noticing symptoms to contacting the general practitioner), cancer symptom recognition, cancer beliefs and barriers to presentation, awareness of campaign messages, healthcare resource use, generic quality of life and individual and area-level deprivation indicators. Consent rates and proportion of missing data for patient questionnaires (n=189) attending RDCs will be measured. Qualitative interviews and focus groups will assess intervention acceptability and barriers/facilitators to delivery.

ETHICS AND DISSEMINATION

Ethical approval for this study was given by the London-West London & GTAC Research Ethics (21/LO/0402). This project will inform a potential future controlled study to assess intervention effectiveness in reducing the patient interval for vague cancer symptoms. The results will be critical to informing national policy and practice regarding behavioural interventions to support RDCs in highly deprived populations.

Family Socioeconomic Position and Lung Cancer Risk: A Meta-Analysis and a Mendelian Randomization Study

Background

Family socioeconomic position (SEP) in childhood is an important factor to predict some chronic diseases. However, the association between family SEP in childhood and the risk of lung cancer is not clear.

Methods

A systematic search was performed to explore their relationship. We selected education level, socioeconomic positions of parents and childhood housing conditions to represent an individual family SEP. Hazard ratios (HRs) of lung cancer specific-mortality were synthesized using a random effects model. Two-sample Mendelian randomization (MR) was carried out with summary data from published genome-wide association studies of SEP to assess the possible causal relationship of SEP and risk of lung cancer.

Results

Through meta-analysis of 13 studies, we observed that to compared with the better SEP, the poorer SEP in the childhood was associated with the increased lung cancer risk in the adulthood (HR: 1.25, 95% CI: 1.10 to 1.43). In addition, the dose-response analysis revealed a positive correlation between the poorer SEP and increased lung cancer risk. Same conclusion was reached in MR [(education level) OR 0.50, 95% CI: 0.39 to 0.63; P &lt; 0.001].

Conclusion

This study indicates that poor family socioeconomic position in childhood is causally correlated with lung cancer risk in adulthood.

Systematic Review Registration

identifier: 159082.

Endometrial cancer

Endometrial cancer is the most common gynaecological cancer in high income countries and its incidence is rising globally. Although an ageing population and fewer benign hysterectomies have contributed to this trend, the growing prevalence of obesity is the major underlying cause. Obesity poses challenges for diagnosis and treatment and more research is needed to offer primary prevention to high-risk women and to optimise endometrial cancer survivorship. Early presentation with postmenopausal bleeding ensures most endometrial cancers are cured by hysterectomy but those with advanced disease have a poor prognosis. Minimally invasive surgical staging and sentinel-lymph-node biopsy provides a low morbidity alternative to historical surgical management without compromising oncological outcomes. Adjuvant radiotherapy reduces loco-regional recurrence in intermediate-risk and high-risk cases. Advances in our understanding of the molecular biology of endometrial cancer have paved the way for targeted chemotherapeutic strategies, and clinical trials will establish their benefit in adjuvant, advanced, and recurrent disease settings in the coming years.

One-stop clinic for patients with suspected ovarian cancer: results from a retrospective outcome study of the referral pathway

Background

Women with abdominal pain and bloating frequently have their Ca-125 levels investigated for suspected ovarian cancer and this has led to a significant increase in referrals to the ovarian cancer service. We have conducted this study to help improve the efficiency in which these patients are investigated and to improve future pathways within the referral service.

Methods

This was a retrospective observational outcome study. Data were collected from electronic documents of patients’ referrals, assessments, and clinical correspondences over 48 months. The study was conducted in a secondary gynaecology cancer centre with direct referrals from primary care. The pelvic mass clinic was set up to include a consultation and an ultrasound scan with support available for patients if required. All patients included were referred directly from primary care for suspected ovarian cancer with Ca-125 result over a period of 2 years.

Results

286 were referred from primary care according to the NICE guidelines of ‘2-week wait for ovarian cancer’. Only 223 patients who had a Ca-125 result reported at the time of their referral were included in the analysis. Out of the 223 patients, 126 patients were discharged with or without a repeat Ca-125 after the initial assessment. 18 patients were diagnosed with cancer following the referral, but only 12 of them had a primary ovarian malignancy. The malignancy rate in women under 50 years of age was 22% (4/18) and 78% (14/18) in women aged 50 or above.

Conclusion

One-stop focused gynaecology ultrasound clinics where clinicians may assess patients and perform ultrasound scans for suspected cancer, may be better for managing this patient population due to improved efficiencies in waiting times, same day diagnosis and a reduction in waiting times to first appointment. Secondly, the majority of the patients with Ca-125 of more than 35 U/mL, who were referred through this pathway, did not have cancer. This review queries the future value of using Ca-125 as the basis for referrals from primary care for suspected ovarian malignancy. Further studies are required to assess whether a higher Ca-125 cut off may be used as the basis of referrals for premenopausal women.

Practical considerations for expediting breast cancer treatment in Brazil

Patients in Brazil continue to present with late-stage breast cancer. Notwithstanding these figures, policies and programs to overcome this long-lasting scenario have had limited results. We enlist the main barriers for advancing breast cancer diagnosis in Brazil, based on the available evidence, and we propose feasible strategies that may serve as a platform to address this major public health challenge.

Randomised controlled trial and economic evaluation of a targeted cancer awareness intervention for adults living in deprived areas of the UK

BACKGROUND

Cancer outcomes are poor in socioeconomically deprived communities, with low symptom awareness contributing to prolonged help-seeking and advanced disease. Targeted cancer awareness interventions require evaluation.

METHODS

This is a randomised controlled trial involving adults aged 40+ years recruited in community and healthcare settings in deprived areas of South Yorkshire and South-East Wales.

INTERVENTION

personalised behavioural advice facilitated by a trained lay advisor.

CONTROL

usual care. Follow-up at two weeks and six months post-randomisation.

PRIMARY OUTCOME

total cancer symptom recognition score two weeks post-randomisation.

RESULTS

Two hundred and thirty-four participants were randomised. The difference in total symptom recognition at two weeks [adjusted mean difference (AMD) 0.6, 95% CI: -0.03, 1.17, p = 0.06] was not statistically significant. Intervention participants reported increased symptom recognition (AMD 0.8, 95% CI: 0.18, 1.37, p = 0.01) and earlier intended presentation (AMD -2.0, 95% CI: -3.02, -0.91, p < 0.001) at six months. "Lesser known" symptom recognition was higher in the intervention arm (2 weeks AMD 0.5, 95% CI: 0.03, 0.97 and six months AMD 0.7, 95% CI: 0.16, 1.17). Implementation cost per participant was £91.34, with no significant between-group differences in healthcare resource use post-intervention.

CONCLUSIONS

Improved symptom recognition and earlier anticipated presentation occurred at longer-term follow-up. The ABACus Health Check is a viable low-cost intervention to increase cancer awareness in socioeconomically deprived communities.

CLINICAL TRIAL REGISTRATION

ISRCTN16872545.

Associations between Fatalistic Cancer Beliefs and Cancer-Screening Behaviors in Chinese American Immigrant Women

Chinese Americans have among the lowest rates of up-to-date cancer screening in the United States. Fatalistic health beliefs are also common in this population and can lead to decreased healthcare utilization. We sought to understand how these fatalistic beliefs are associated with cancer screening behaviors in this underserved population. A cross-sectional survey was conducted with 732 Chinese women from the greater Chinatown area of Chicago, Illinois. Surveyed questions included sociodemographic information, self-reported healthcare utilization and cancer screening behaviors. The majority of respondents were older than 50, spoke Chinese, had less than a college education, public or no medical insurance, and an annual income  < $20,000. Approximately 20% had never received Papanicolaou or mammogram screening. Fatalistic beliefs were common and associated with increased health-seeking behaviors and appropriate Pap and mammogram screening. In this cohort of Chinese American immigrant women in an urban Chinatown community, fatalistic cancer beliefs were prevalent and associated with increased health-seeking and positive cancer screening behaviors. This previously unreported relationship could be leveraged in improving health outcomes of an underserved population.

Patient characteristics and healthcare utilisation among Danish patients with chronic conditions: a nationwide cohort study in general practice and hospitals

Background

The complexity of caring for patients with chronic conditions necessitates new models of integrated care to accommodate an increasing demand. To inform the development of integrated care models, it is essential to map patients’ use of healthcare resources. In this nationwide registry-based cohort study, we describe and compare patient characteristics and healthcare utilisation between Danish patients with chronic conditions in general practice follow-up and in hospital outpatient follow-up.

Methods

On 1 January 2016, we identified 250,402 patients registered in 2006–2015 with a hospital diagnosis of atrial fibrillation/flutter, congestive heart failure, chronic liver disease, inflammatory bowel disease or chronic obstructive pulmonary disease. By linkage to national social and health registries, patient characteristics and 12-month healthcare utilisation were extracted. Incidence rates of health care utilisation were compared between patients with chronic conditions in general practice follow-up and patients in hospital outpatient follow-up using negative binomial regression.

Results

Across all five conditions, the largest proportions of patients were in general practice follow-up (range = 59–87%). Patients in hospital outpatient follow-up had higher rates of exacerbation-related admissions (adjusted incidence rate ratio (IRR) range = 1.3 to 2.8) and total length of stay (IRR range = 1.2 to 2.2). For these five conditions, all-cause admissions and lengths of stay, general practice daytime and out-of-hours contacts, and municipal home nursing contacts were similar between follow-up groups or higher among patients in general practice follow-up. The exception was patients with chronic obstructive pulmonary disease, where patients in hospital outpatient follow-up had higher utilisation of healthcare resources.

Conclusions

Patients in general practice follow-up accounted for the largest proportion of total healthcare utilisation, but patients in hospital outpatient follow-up were characterised by high exacerbation rates. Enhanced integration of chronic care may be of most benefit if patients in general practice follow-up are targeted, but it is also likely to have an impact on exacerbation rates among patients in hospital outpatient follow-up.

Breast Cancer Screening Trends among Lower Income Women of New York: A Time-Series Evaluation of a Population-Based Intervention

OBJECTIVE

This study aimed to compare the screening rate trends of mammography among New York State's lower-income women and the higher-income women from 1988 to 2010, and evaluate the potential influence of New York State's Breast Cancer Early Detection Program (introduced in 1994) on the mammography use rates of lower-income women.

MATERIALS AND METHODS

Lower-income women are defined as women aged 40 and over whose household income is lower than 250% of the single member household federal poverty level (FPL) in the year that they participated in the survey. Higher-income women are defined as women aged 40 and over whose income is greater than 250% of the five-person household FPL. Data were obtained from the Behavioral Risk Factor Surveillance System. Interrupted time series analysis was conducted to examine screening rates before and after the launch of the Breast Cancer Early Detection program.

RESULTS

Among the lower-income women, the pre-intervention mammography screening rate significantly increased by an average of 15.21% every two years. However, after implementation of the Breast Cancer Early Detection Program, this rate of increase significantly slowed (slope change=-13.67, p=0.00016). The lower-income women and the higher-income women experienced a similar trend change after the intervention started.

CONCLUSION

This study found limited evidence that the Breast Cancer Early Detection Programme significantly contributed to the state-wide increase in mammography screening rate among lower-income women from 1988 to 2010. Future studies should examine the influence of structural and individual barriers inhibiting uptake of mammography screening among lower-income women.

Providing healthcare through “value shops”: impact on professional fulfilment for physicians and nurses

Purpose

The purpose of this paper is to empirically explore and demonstrate the ability of healthcare professionals to attain professional fulfilment when providing healthcare inspired by “value shops”.

Design/methodology/approach

A qualitative case study incorporating interviews and observations was conducted.

Findings

The empirical data suggest that the professional fulfilment of both physicians and nurses is facilitated when care is organized through “value shops”. Both groups of professionals state that they are able to return to their “professional core”.

Originality/value

The beneficial outcomes of organizing healthcare inspired by the “value shop” have previously been explored in terms of efficiency and quality. However, the professional fulfilment of healthcare professionals when providing such care has not been explicitly addressed. Professional fulfilment is vital in order to safeguard high-quality care, as well as healthcare professionals' involvement and engagement in implementing quality improvements. This paper highlights the fact that care provision inspired by the “value shop” may facilitate professional fulfilment, which further strengthens the potential positive outcomes of the “value shop” when utilized in a healthcare setting.

The impact of ultrasound in an integrated one-stop sarcoma clinic

AIM

To evaluate the utilisation of ultrasound within a one-stop clinic model in a regional bone and soft-tissue sarcoma centre in the UK, assess its contribution to patient management, and compare diagnostic outcomes to general musculoskeletal "lumps and bumps" clinics.

MATERIALS AND METHODS

This study was a retrospective evaluation of 1,918 referrals between October 2016 and September 2018. All ultrasound examinations and biopsies were performed by one of two musculoskeletal sarcoma radiologists. Ultrasound criteria for suspicion of malignancy were agreed. Study parameters included patient demographics, imaging modality, imaging findings, biopsy results, and time intervals. Correlation has been made between imaging findings and biopsy results.

RESULTS

Five hundred and twenty-four patients (27%) underwent diagnostic ultrasound within the one-stop clinic, out of which 244 (46.5%) underwent an ultrasound-guided biopsy within the same appointment. From this cohort, 412 (78.6%) were given a likely benign diagnosis, either based on imaging alone or in combination with an ultrasound-guided biopsy and a histologically malignant diagnosis was made in the remaining 112 (21.4%). Diagnostic ultrasound within the one-stop sarcoma clinic has a positive predictive value of 86%, negative predictive value of 97%, and sensitivity of 89%.

CONCLUSION

Integration of ultrasound within a one-stop sarcoma clinic provides rapid diagnostic imaging input within the outpatient setting and facilitates early effective triaging of patients into appropriate management plans. It reduces waiting times, unnecessary outpatient appointments and short-term patient anxiety. Clinical and communications skills of the sarcoma radiologist are of paramount importance to improving overall efficiency and patient experience.