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Round T, Sethuraman L, Ashworth M, Purushotham A. Transforming post pandemic cancer services. Br J Cancer 2024; 130:1233-1238. [PMID: 38491174 PMCID: PMC11014976 DOI: 10.1038/s41416-024-02596-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 11/15/2023] [Accepted: 01/19/2024] [Indexed: 03/18/2024] Open
Abstract
This paper outlines the impact of the COVID-19 pandemic on cancer services in the UK including screening, symptomatic diagnosis, treatment pathways and projections on clinical outcomes as a result of these care disruptions. A restoration of cancer services to pre-pandemic levels is not likely to mitigate this adverse impact, particularly with an ageing population and increased cancer burden. New cancer cases are projected to rise to over 500,000 per year by 2035, with over 4 million people living with and beyond cancer. This paper calls for a strategic transformation to prioritise effort on the basis of available datasets and evidence-in particular, to prioritise cancers where an earlier diagnosis is feasible and clinically useful with a focus on mortality benefit by preventing emergency presentations by harnessing data and analytics. This could be delivered by a focus on underperforming groups/areas to try and reduce inequity, linking near real-time datasets with clinical decision support systems at the primary and secondary care levels, promoting the use of novel technologies to improve patient uptake of services, screening and diagnosis, and finally, upskilling and cross-skilling healthcare workers to expand supply of diagnostic and screening services.
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Affiliation(s)
- Thomas Round
- School of Life Course and Population Sciences, King's College London, London, UK.
| | | | - Mark Ashworth
- School of Life Course and Population Sciences, King's College London, London, UK
| | - Arnie Purushotham
- School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
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Scott SE, Gildea C, Nicholson BD, Evans RE, Waller J, Smith D, Purushotham A, Round T. Future cancer risk after urgent suspected cancer referral in England when cancer is not found: a national cohort study. Lancet Oncol 2023; 24:1242-1251. [PMID: 37922929 DOI: 10.1016/s1470-2045(23)00435-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 08/16/2023] [Accepted: 08/17/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Following referral for investigation of urgent suspected cancer within the English National Health Service referral system, 7% of referred individuals are diagnosed with cancer. This study aimed to investigate the risk of cancer occurrence within 1-5 years of finding no cancer following an urgent suspected cancer referral. METHODS This national cohort study used urgent suspected cancer referral data for England from the Cancer Waiting Times dataset and linked it with cancer diagnosis data from the National Cancer Registration dataset. Data were extracted for the eight most commonly referred to urgent suspected cancer referral pathways (breast, gynaecological, head and neck, lower and upper gastrointestinal, lung, skin, and urological) for the period April 1, 2013, to March 31, 2014, with 5-year follow-up for individuals with no cancer diagnosis within 1 year of referral. The primary objective was to investigate the occurrence and type of subsequent cancer in years 1-5 following an urgent suspected cancer referral when no cancer was initially found, both overall and for each of the eight referral pathways. The numbers of subsequent cancers were compared with expected cancer incidence in years 1-5 following referral, using standardised incidence ratios (SIRs) based on matched age-gender distributions of expected cancer incidence in England for the same time period. The analysis was repeated, stratifying by referral group, and by calculating the absolute and expected rate of all cancers and of the same individual cancer as the initial referral. FINDINGS Among 1·18 million referrals without a cancer diagnosis in years 0-1, there were 63 112 subsequent cancers diagnosed 1-5 years post-referral, giving an absolute rate of 1338 (95% CI 1327-1348) cancers per 100 000 referrals per year (1038 [1027-1050] in females, 1888 [1867-1909] in males), compared with an expected rate of 1054 (1045-1064) cancers per 100 000 referrals per year (SIR 1·27 [95% CI 1·26-1·28]). The absolute rate of any subsequent cancer diagnosis 1-5 years after referral was lowest following suspected breast cancer referral (746 [728-763] cancers per 100 000 referrals per year) and highest following suspected urological (2110 [2070-2150]) or lung cancer (1835 [1767-1906]) referral. For diagnosis of the same cancer as the initial referral pathway, the highest absolute rates were for the urological and lung pathways (1011 [984-1039] and 638 [598-680] cancers per 100 000 referrals per year, respectively). The highest relative risks of subsequent diagnosis of the same cancer as the initial referral pathway were for the head and neck pathway (SIR 3·49 [95% CI 3·22-3·78]) and lung pathway (3·00 [2·82-3·20]). INTERPRETATION Cancer risk was higher than expected in the 5 years following an urgent suspected cancer referral. The potential for targeted interventions, such as proactive monitoring, safety-netting, and cancer awareness or risk reduction initiatives should be investigated. FUNDING Cancer Research UK.
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Affiliation(s)
- Suzanne E Scott
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK; King's College London, London, UK.
| | | | - Brian D Nicholson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ruth E Evans
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | | | | | | | - Thomas Round
- King's College London, London, UK; National Disease Registration Service, NHS England, UK
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Dixit N, Rodriguez G, Sarkar U, Burke N, Trejo E, Devore DJ, Couey P, Nápoles AM. Identifying the Needs of Primary Care Providers Caring for Breast and Colon Cancer Survivors in the Safety-Net: a Qualitative Study. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2023; 38:845-853. [PMID: 35829986 PMCID: PMC10234859 DOI: 10.1007/s13187-022-02195-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/23/2022] [Indexed: 05/07/2023]
Abstract
As the number of cancer survivors continues to increase and given the shortage of oncology clinicians in safety net health care settings, primary care providers (PCPs) in these settings will increasingly provide cancer survivorship care. In order to ensure equitable care for low-income and underserved breast and colon cancer survivors, it is essential to understand the safety-net PCPs' perspective. We conducted semi-structured, in-depth qualitative interviews with 11 PCPs working in a safety-net health care system to identify their needs in caring for cancer survivors. Interviews were audio-recorded and professionally transcribed. Two coders independently coded the interviews and conducted regular meetings until we reached consensus on the results. Analysis was based in grounded theory and performed using the constant comparative method. Thematic analysis identified six themes as follows: (1) Cancer survivorship care can be integrated with the whole person and chronic disease care management that occurs in primary care; (2) PCPs' perceptions regarding patients' survivorship care needs and their confidence in meeting those needs; (3) preference for a shared care model; (4) coordination of care; (5) PCPs' need for survivorship care education and training; and (6) unique issues involved in the care of older cancer survivors. PCPs in the safety-net believe that providing comprehensive survivorship care requires coordination of care through the cancer continuum. Tools like checklists, electronic health records-based communication, and convenient electronic consultations with cancer specialists would enhance the quality of survivorship care. Respondents advocate the inclusion of survivorship care education in medical education. The continuity of care with PCPs means that they play a particularly important role in the care of older cancer survivors.
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Affiliation(s)
- Niharika Dixit
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA.
| | - Gladys Rodriguez
- Hematology/Oncology, Stanford School of Medicine, Palo Alto, CA, USA
| | - Urmimala Sarkar
- Division of General Internal Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
- Center for Vulnerable Populations, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Nancy Burke
- School of Social Sciences, Humanities, and Arts, University of California Merced, Merced, CA, USA
| | - Evelin Trejo
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | | | - Paul Couey
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Anna María Nápoles
- Division of Intramural Research, National Institute On Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, USA
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Parween S, Asthana A, Nahar P. Fundamentals of Image-Based Assay (IBA) System for Affordable Point of Care Diagnostics. Microchem J 2022. [DOI: 10.1016/j.microc.2022.108345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Cancer detection via primary care urgent referral and association with practice characteristics: a retrospective cross-sectional study in England from 2009/2010 to 2018/2019. Br J Gen Pract 2021; 71:e826-e835. [PMID: 34544690 PMCID: PMC8463132 DOI: 10.3399/bjgp.2020.1030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 05/17/2021] [Indexed: 11/17/2022] Open
Abstract
Background There is substantial variation in the use of urgent suspected cancer referral (2-week wait [2WW]) between practices. Aim To examine the change in use of 2WW referrals in England over 10 years (2009/2010 to 2018/2019) and the practice and population factors associated with cancer detection. Design and setting Retrospective cross-sectional study of English general practices and their 2WW referral and Cancer Waiting Times database detection data (all cancers other than non-melanoma skin cancers) from 2009/2010 to 2018/2019. Method A retrospective study conducted using descriptive statistics of changes over 10 years in 2WW referral data. Yearly linear regression models were used to determine the association between cancer detection rates and quintiles of practice and population characteristics. Predicted cancer detection rates were calculated, as well as the difference between lowest to highest quintiles. Results Over the 10 years studied there were 14.89 million 2WW referrals (2.24 million in 2018/2019), and 2.68 million new cancer diagnoses, of which 1.26 million were detected following 2WW. The detection rate increased from 41% to 52% over the time period. In 2018/2019 an additional 66 172 cancers were detected via 2WW compared with 2009/2010. Higher cancer detection via 2WW referrals was associated with larger practices and those with younger GPs. From 2016/2017 onwards more deprived practice populations were associated with decreased cancer detection. Conclusion From 2009/2010 to 2018/2019 2WW referrals increased on average by 10% year on year. The most consistent association with higher cancer detection was found for larger practices and those with younger GPs, though these differences became attenuated over time. The more recent association between increased practice deprivation and lower cancer detection is a cause for concern. The COVID-19 pandemic has led to significant impacts on 2WW referral activity and the impact on patient outcomes will need to be studied.
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Disbeschl S, Surgey A, Roberts JL, Hendry A, Lewis R, Goulden N, Hoare Z, Williams N, Anthony BF, Edwards RT, Law RJ, Hiscock J, Carson-Stevens A, Neal RD, Wilkinson C. Protocol for a feasibility study incorporating a randomised pilot trial with an embedded process evaluation and feasibility economic analysis of ThinkCancer!: a primary care intervention to expedite cancer diagnosis in Wales. Pilot Feasibility Stud 2021; 7:100. [PMID: 33883033 PMCID: PMC8059131 DOI: 10.1186/s40814-021-00834-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 04/07/2021] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Compared to the rest of Europe, the UK has relatively poor cancer outcomes, with late diagnosis and a slow referral process being major contributors. General practitioners (GPs) are often faced with patients presenting with a multitude of non-specific symptoms that could be cancer. Safety netting can be used to manage diagnostic uncertainty by ensuring patients with vague symptoms are appropriately monitored, which is now even more crucial due to the ongoing COVID-19 pandemic and its major impact on cancer referrals. The ThinkCancer! workshop is an educational behaviour change intervention aimed at the whole general practice team, designed to improve primary care approaches to ensure timely diagnosis of cancer. The workshop will consist of teaching and awareness sessions, the appointment of a Safety Netting Champion and the development of a bespoke Safety Netting Plan and has been adapted so it can be delivered remotely. This study aims to assess the feasibility of the ThinkCancer! intervention for a future definitive randomised controlled trial. METHODS The ThinkCancer! study is a randomised, multisite feasibility trial, with an embedded process evaluation and feasibility economic analysis. Twenty-three to 30 general practices will be recruited across Wales, randomised in a ratio of 2:1 of intervention versus control who will follow usual care. The workshop will be delivered by a GP educator and will be adapted iteratively throughout the trial period. Baseline practice characteristics will be collected via questionnaire. We will also collect primary care intervals (PCI), 2-week wait (2WW) referral rates, conversion rates and detection rates at baseline and 6 months post-randomisation. Participant feedback, researcher reflections and economic costings will be collected following each workshop. A process evaluation will assess implementation using an adapted Normalisation Measure Development (NoMAD) questionnaire and qualitative interviews. An economic feasibility analysis will inform a future economic evaluation. DISCUSSION This study will allow us to test and further develop a novel evidenced-based complex intervention aimed at general practice teams to expedite the diagnosis of cancer in primary care. The results from this study will inform the future design of a full-scale definitive phase III trial. TRIAL REGISTRATION ClinicalTrials.gov NCT04823559 .
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Affiliation(s)
- Stefanie Disbeschl
- North Wales Centre for Primary Care Research (NWCPCR), Bangor University, Cambrian 2, Wrexham Technology Park, Wrexham, LL13 7YP, UK.
| | - Alun Surgey
- North Wales Centre for Primary Care Research (NWCPCR), Bangor University, Cambrian 2, Wrexham Technology Park, Wrexham, LL13 7YP, UK
| | - Jessica L Roberts
- North Wales Centre for Primary Care Research (NWCPCR), Bangor University, Cambrian 2, Wrexham Technology Park, Wrexham, LL13 7YP, UK
| | - Annie Hendry
- North Wales Centre for Primary Care Research (NWCPCR), Bangor University, Cambrian 2, Wrexham Technology Park, Wrexham, LL13 7YP, UK
| | - Ruth Lewis
- North Wales Centre for Primary Care Research (NWCPCR), Bangor University, Cambrian 2, Wrexham Technology Park, Wrexham, LL13 7YP, UK
| | - Nia Goulden
- North Wales Organisation for Randomised Trials in Health (NWORTH), Bangor University, The Normal Site, Holyhead Road, Gwynedd, LL57 2PZ, UK
| | - Zoe Hoare
- North Wales Organisation for Randomised Trials in Health (NWORTH), Bangor University, The Normal Site, Holyhead Road, Gwynedd, LL57 2PZ, UK
| | - Nefyn Williams
- Department of Primary Care and Mental Health, Institute of Population Health, University of Liverpool, Liverpool, L69 3GL, UK
| | - Bethany Fern Anthony
- Centre for Health Economics and Medicines Evaluation (CHEME), Bangor University, The Normal Site, Holyhead Road, Gwynedd, LL57 2PZ, UK
| | - Rhiannon Tudor Edwards
- Centre for Health Economics and Medicines Evaluation (CHEME), Bangor University, The Normal Site, Holyhead Road, Gwynedd, LL57 2PZ, UK
| | - Rebecca-Jane Law
- North Wales Centre for Primary Care Research (NWCPCR), Bangor University, Cambrian 2, Wrexham Technology Park, Wrexham, LL13 7YP, UK
| | - Julia Hiscock
- North Wales Centre for Primary Care Research (NWCPCR), Bangor University, Cambrian 2, Wrexham Technology Park, Wrexham, LL13 7YP, UK
| | - Andrew Carson-Stevens
- Division of Population Medicine, School of Medicine, Cardiff University, UHW Main Building, Heath Park, Cardiff, CF14 4XN, UK
| | - Richard D Neal
- Academic Unit of Primary Care, Leeds Institute of Health Sciences, University of Leeds, Worsley Building, Leeds, LS2 9NL, UK
| | - Clare Wilkinson
- North Wales Centre for Primary Care Research (NWCPCR), Bangor University, Cambrian 2, Wrexham Technology Park, Wrexham, LL13 7YP, UK
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Association between use of urgent suspected cancer referral and mortality and stage at diagnosis: a 5-year national cohort study. Br J Gen Pract 2020; 70:e389-e398. [PMID: 32312762 PMCID: PMC7176359 DOI: 10.3399/bjgp20x709433] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 12/16/2019] [Indexed: 02/06/2023] Open
Abstract
Background There is considerable variation between GP practices in England in their use of urgent referral pathways for suspected cancer. Aim To determine the association between practice use of urgent referral and cancer stage at diagnosis and cancer patient mortality, for all cancers and the most common types of cancer (colorectal, lung, breast, and prostate). Design and setting National cohort study of 1.4 million patients diagnosed with cancer in England between 2011 and 2015. Method The cohort was stratified according to quintiles of urgent referral metrics. Cox proportional hazards regression was used to quantify risk of death, and logistic regression to calculate odds of late-stage (III/IV) versus early-stage (I/II) cancers in relation to referral quintiles and cancer type. Results Cancer patients from the highest referring practices had a lower hazard of death (hazard ratio [HR] = 0.96; 95% confidence interval [CI] = 0.95 to 0.97), with similar patterns for individual cancers: colorectal (HR = 0.95; CI = 0.93 to 0.97); lung (HR = 0.95; CI = 0.94 to 0.97); breast (HR = 0.96; CI = 0.93 to 0.99); and prostate (HR = 0.88; CI = 0.85 to 0.91). Similarly, for cancer patients from these practices, there were lower odds of late-stage diagnosis for individual cancer types, except for colorectal cancer. Conclusion Higher practice use of referrals for suspected cancer is associated with lower mortality for the four most common types of cancer. A significant proportion of the observed mortality reduction is likely due to earlier stage at diagnosis, except for colorectal cancer. This adds to evidence supporting the lowering of referral thresholds and consequent increased use of urgent referral for suspected cancer.
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Round T, Abel G. Seeing the wood and the trees: the impact of the healthcare system on variation in primary care referrals. BMJ Qual Saf 2019; 29:274-276. [PMID: 31822513 DOI: 10.1136/bmjqs-2019-010356] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2019] [Indexed: 01/23/2023]
Affiliation(s)
- Thomas Round
- School of Population Health and Environmental Sciences, King's College London, London, UK
| | - Gary Abel
- Medical School (Primary Care), University of Exeter, Exeter, UK
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