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Mitchell RJ, Delaney GP, Arnolda G, Liauw W, Lystad RP, Braithwaite J. Survival of patients who had cancer diagnosed through an emergency hospital admission: A retrospective matched case-comparison study in Australia. Cancer Epidemiol 2024; 91:102584. [PMID: 38772062 DOI: 10.1016/j.canep.2024.102584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 04/30/2024] [Accepted: 05/12/2024] [Indexed: 05/23/2024]
Abstract
BACKGROUND Individuals diagnosed with cancer via emergency admission are likely to have poor outcomes. This study aims to identify cancer diagnosed through an emergency hospital admission and examine predictors associated with mortality within 12-months. METHOD A population-based retrospective 1:1 propensity-matched case-comparison study of people who had an emergency versus a planned hospital admission with a principal diagnosis of cancer during 2013-2020 in New South Wales, Australia using linked hospital, cancer registry and mortality records. Conditional logistic regression examined predictors of mortality at 12-months. RESULTS There were 28,502 matched case-comparisons. Individuals who had an emergency admission were four times more likely to die within 12-months (Odds Ratio (OR) 3.93; 95 % confidence interval (CI) 3.75-4.13) compared to individuals who had a planned admission for cancer. Older individuals, diagnosed with lung (OR 1.89; 95 %CI 1.36-2.63) or digestive organ, excluding colorectal (OR1.78; 95 %CI 1.30-2.43) cancers, where the degree of spread was metastatic (OR 3.61; 95 %CI 2.62-4.50), who had a mental disorder diagnosis (OR 2.08; 95 %CI 1.89-2.30), lived in rural (OR 1.27; 95 %CI 1.17-1.37) or more disadvantaged neighbourhoods had a higher likelihood of death within 12-months following an unplanned admission compared to referent groups. Females (OR 0.87; 95 %CI 0.81-0.93) had an 13 % lower likelihood of mortality within 12-months compared to males. CONCLUSIONS While some emergency cancer admissions are not avoidable, the importance of preventive screening and promotion of help-seeking for early cancer symptoms should not be overlooked as mechanisms to reduce emergency admissions related to cancer and to improve cancer survival.
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Affiliation(s)
- Rebecca J Mitchell
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia.
| | - Geoffrey P Delaney
- Maridulu Budyari Gumal - Sydney Partnership for Health, Education, Research and Enterprise (SPHERE), UNSW, Sydney, Australia; Cancer Therapy Centre, Liverpool Hospital, Sydney, Australia; Collaboration for Cancer Outcomes Research and Evaluation, South-Western Sydney Clinical School, UNSW, Sydney, Australia; University of New South Wales School of Clinical Medicine, Sydney, Australia
| | - Gaston Arnolda
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - Winston Liauw
- University of New South Wales School of Clinical Medicine, Sydney, Australia; Cancer Care Centre, St George Hospital, Kogarah, Australia
| | - Reidar P Lystad
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - Jeffrey Braithwaite
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
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Rafiq M, Drosdowsky A, Solomon B, Alexander M, Gibbs P, Wright G, Yeung JM, Lyratzopoulos G, Emery J. Trends in primary care blood tests prior to lung and colorectal cancer diagnosis-A retrospective cohort study using linked Australian data. Cancer Med 2024; 13:e70006. [PMID: 39001673 PMCID: PMC11245636 DOI: 10.1002/cam4.70006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 06/20/2024] [Accepted: 06/30/2024] [Indexed: 07/16/2024] Open
Abstract
INTRODUCTION Abnormal results in common blood tests may occur several months before lung cancer (LC) and colorectal cancer (CRC) diagnosis. Identifying early blood markers of cancer and distinct blood test signatures could support earlier diagnosis in general practice. METHODS Using linked Australian primary care and hospital cancer registry data, we conducted a cohort study of 855 LC and 399 CRC patients diagnosed between 2001 and 2021. Requests and results from general practice blood tests (six acute phase reactants [APR] and six red blood cell indices [RBCI]) were examined in the 2 years before cancer diagnosis. Poisson regression models were used to estimate monthly incidence rates and examine pre-diagnostic trends in blood test use and abnormal results prior to cancer diagnosis, comparing patterns in LC and CRC patients. RESULTS General practice blood test requests increase from 7 months before CRC and 6 months before LC diagnosis. Abnormalities in many APR and RBCI tests increase several months before cancer diagnosis, often occur prior to or in the absence of anaemia (in 51% of CRC and 81% of LC patients with abnormalities), and are different in LC and CRC patients. CONCLUSIONS This study demonstrates an increase in diagnostic activity in Australian general practice several months before LC and CRC diagnosis, indicating potential opportunities for earlier diagnosis. It identifies blood test abnormalities and distinct signatures that are early markers of LC and CRC. If combined with other pre-diagnostic information, these blood tests have potential to support GPs in prioritising patients for cancer investigation of different sites to expedite diagnosis.
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Affiliation(s)
- Meena Rafiq
- Department of General Practice and Centre for Cancer Research, University of Melbourne, Melbourne, Victoria, Australia
- Epidemiology of Cancer Healthcare & Outcomes (ECHO) Group, Department of Behavioural Science and Health, Institute of Epidemiology and Health Care (IECH), UCL, London, UK
| | - Allison Drosdowsky
- Department of General Practice and Centre for Cancer Research, University of Melbourne, Melbourne, Victoria, Australia
| | - Ben Solomon
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | | | - Peter Gibbs
- Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia
| | - Gavin Wright
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Justin M Yeung
- Department of Surgery, Western Precinct, University of Melbourne, Melbourne, Victoria, Australia
| | - Georgios Lyratzopoulos
- Epidemiology of Cancer Healthcare & Outcomes (ECHO) Group, Department of Behavioural Science and Health, Institute of Epidemiology and Health Care (IECH), UCL, London, UK
| | - Jon Emery
- Department of General Practice and Centre for Cancer Research, University of Melbourne, Melbourne, Victoria, Australia
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Exarchakou A, Rachet B, Lyratzopoulos G, Maringe C, Rubio FJ. What can hospital emergency admissions prior to cancer diagnosis tell us about socio-economic inequalities in cancer diagnosis? Evidence from population-based data in England. Br J Cancer 2024; 130:1960-1968. [PMID: 38671209 PMCID: PMC11182764 DOI: 10.1038/s41416-024-02688-6] [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: 10/07/2022] [Revised: 04/07/2024] [Accepted: 04/09/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND More deprived cancer patients are at higher risk of Emergency Presentation (EP) with most studies pointing to lower symptom awareness and increased comorbidities to explain those patterns. With the example of colon cancer, we examine patterns of hospital emergency admissions (HEAs) history in the most and least deprived patients as a potential precursor of EP. METHODS We analysed the rates of hospital admissions and their admission codes (retrieved from Hospital Episode Statistics) in the two years preceding cancer diagnosis by sex, deprivation and route to diagnosis (EP, non-EP). To select the conditions (grouped admission codes) that best predict emergency admission, we adapted the purposeful variable selection to mixed-effects logistic regression. RESULTS Colon cancer patients diagnosed through EP had the highest number of HEAs than all the other routes to diagnosis, especially in the last 7 months before diagnosis. Most deprived patients had an overall higher rate and higher probability of HEA but fewer conditions associated with it. CONCLUSIONS Our findings point to higher use of emergency services for non-specific symptoms and conditions in the most deprived patients, preceding colon cancer diagnosis. Health system barriers may be a shared factor of socio-economic inequalities in EP and HEAs.
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Affiliation(s)
- Aimilia Exarchakou
- Inequalities in Cancer Outcomes Network (ICON), Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK.
| | - Bernard Rachet
- Inequalities in Cancer Outcomes Network (ICON), Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Georgios Lyratzopoulos
- Epidemiology of Cancer Healthcare and Outcomes (ECHO), Department of Behavioural Science and Health, Institute of Epidemiology and Health Care, University College London, London, UK
| | - Camille Maringe
- Inequalities in Cancer Outcomes Network (ICON), Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
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O'Neill OM, Coleman HG, Reid H. Referral challenges for early-onset colorectal cancer: a qualitative study in UK primary care. BJGP Open 2023; 7:BJGPO.2023.0123. [PMID: 37433643 PMCID: PMC11176685 DOI: 10.3399/bjgpo.2023.0123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 07/05/2023] [Accepted: 07/06/2023] [Indexed: 07/13/2023] Open
Abstract
BACKGROUND The incidence of early-onset colorectal cancer (EOCRC) in adults aged <50 years has increased in several Western nations. National surveys have highlighted significant barriers to accessing timely care for patients with EOCRC, which may be contributing to a late stage of presentation in this population group. AIM To explore awareness of the increasing incidence of EOCRC, and to understand the potential barriers or facilitators faced by GPs when referring younger adults to secondary care with features indicative of EOCRC. DESIGN & SETTING Qualitative methodology, via virtual semi-structured interviews with 17 GPs in Northern Ireland. METHOD Reflective thematic analysis was conducted with reference to Braun and Clarke's framework. RESULTS Three main themes were identified among participating GPs: awareness, diagnostic, and referral challenges. Awareness challenges focused on perceptions of EOCRC being solely associated with hereditary cancer syndromes, and colorectal cancer being a condition of older adults. Key diagnostic challenges centred around the commonality of lower gastrointestinal complaints and overlap in EOCRC symptoms with benign conditions. Restrictions in age-based referral guidance and a GP 'guilt complex' surrounding over-referral to secondary care summarised the referral challenges. Young females were perceived as being particularly disadvantaged with regard to delays in diagnosis. CONCLUSION This novel research outlines potential reasons for the diagnostic delays seen in patients with EOCRC from a GP perspective, and highlights many of the complicating factors that contribute to the diagnostic process.
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Affiliation(s)
- Orla M O'Neill
- Cancer Epidemiology Research Group, Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland, UK
- Dunluce Health Centre, Belfast, Northern Ireland, UK
| | - Helen G Coleman
- Cancer Epidemiology Research Group, Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland, UK
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Helen Reid
- Dunluce Health Centre, Belfast, Northern Ireland, UK
- Centre for Medical Education, Queen's University Belfast, Belfast, Northern Ireland, UK
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Wickramasinghe D, Kamburugamuwa S, Xavier C, Samarasekera N, Warusavitarne J. Prevalence of irritable bowel syndrome and its association with colorectal cancer: a systematic review and meta-analysis. ANZ J Surg 2023. [PMID: 36757832 DOI: 10.1111/ans.18223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 12/06/2022] [Accepted: 12/14/2022] [Indexed: 02/10/2023]
Abstract
BACKGROUND This study evaluates the risk of colorectal cancer (CRC) in patients with Irritable Bowel Syndrome (IBS). METHODS A literature search was performed on MEDLINE, EMBASE, SCOPUS, and Google Scholar from inception to 31st January 2020 without any limitations on article type or language for studies reporting data on CRC on patients with IBS. A meta-analysis was performed to estimate the prevalence of CRC among patients with IBS. Data extraction was according to the PRISMA guidelines. The quality of the included studies was assessed according to the Newcastle Ottawa Scale. RESULTS Twenty-one articles were eligible for data extraction and quantitative analysis. Of them, 11 were included in the meta-analysis (IBS n = 284 366, no-IBS n = 8 390 509). The pooled prevalence of CRC in patients with IBS was 0.96% (95% CI-0.184%-2.344%). The prevalence was lowest in the constipation-predominant IBS (pooled prevalence 1.126%. Patients with IBS-D and IBS-U had an equal pooled prevalence of CRC (2.49%). Eleven studies compared the prevalence of CRC in patients with IBS with a control population. The pooled OR was 2.8 (CI 2.305-3.294). CONCLUSIONS There was an increased risk of CRC among patients diagnosed with IBS, primarily in the first year after IBS diagnosis. REGISTRATION The review was registered on PROSPERO (CRD42021236707).
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Affiliation(s)
| | - Sohan Kamburugamuwa
- Department of Surgery, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Chrisjit Xavier
- Department of Surgery, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
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Exarchakou A, Kipourou DK, Belot A, Rachet B. Socio-economic inequalities in cancer survival: how do they translate into Number of Life-Years Lost? Br J Cancer 2022; 126:1490-1498. [PMID: 35149855 PMCID: PMC9090931 DOI: 10.1038/s41416-022-01720-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 01/15/2022] [Accepted: 01/26/2022] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND We aimed to investigate the impact of socio-economic inequalities in cancer survival in England on the Number of Life-Years Lost (NLYL) due to cancer. METHODS We analysed 1.2 million patients diagnosed with one of the 23 most common cancers (92.3% of all incident cancers in England) between 2010 and 2014. Socio-economic deprivation of patients was based on the income domain of the English Index of Deprivation. We estimated the NLYL due to cancer within 3 years since diagnosis for each cancer and stratified by sex, age and deprivation, using a non-parametric approach. The relative survival framework enables us to disentangle death from cancer and death from other causes without the information on the cause of death. RESULTS The largest socio-economic inequalities were seen mostly in adults <45 years with poor-prognosis cancers. In this age group, the most deprived patients with lung, pancreatic and oesophageal cancer lost up to 6 additional months within 3 years since diagnosis than the least deprived. For most moderate/good prognosis cancers, the socio-economic inequalities widened with age. CONCLUSIONS More deprived patients and particularly the young with more lethal cancers, lose systematically more life-years than the less deprived. To reduce these inequalities, cancer policies should systematically encompass the inequities component.
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Affiliation(s)
- Aimilia Exarchakou
- Inequalities in Cancer Outcomes Network (ICON), Department of Non-Communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Dimitra-Kleio Kipourou
- Inequalities in Cancer Outcomes Network (ICON), Department of Non-Communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Aurélien Belot
- Inequalities in Cancer Outcomes Network (ICON), Department of Non-Communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Bernard Rachet
- Inequalities in Cancer Outcomes Network (ICON), Department of Non-Communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
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Pre-diagnostic clinical features and blood tests in patients with colorectal cancer: a retrospective linked data study. Br J Gen Pract 2022; 72:e556-e563. [PMID: 35667682 PMCID: PMC9183460 DOI: 10.3399/bjgp.2021.0563] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 02/21/2022] [Indexed: 10/31/2022] Open
Abstract
Background: The majority of colorectal cancer cases are diagnosed following symptomatic presentation in the United Kingdom. Aim: To identify windows of opportunity for timely investigations or referrals in patients presenting with colon and rectal cancer-relevant symptoms or abnormal blood tests. Design and setting: Retrospective cohort study using linked primary care and cancer registry data of colorectal cancer patients diagnosed in England between 2012-2015. Methods: Monthly consultation rates for relevant clinical features (change in bowel habit, rectal bleeding, abdominal pain, mass, constitutional symptoms, and other bowel symptoms) and abnormal blood test results (low haemoglobin, high platelets and inflammatory markers) up to 24 months pre-diagnosis were calculated. Poisson regression adjusted for age, sex and relevant comorbidities was used to estimate the most likely month when consultation rates increased above baseline trend. Results: 5033 colon and 2516 rectal cancer patients were included. Consultations for all examined clinical features and abnormal blood tests increased in the year pre-diagnosis. Rectal bleeding was the earliest clinical feature to increase from baseline rate: 10 months (95%CI 8.3-11.7) pre-diagnosis for colon cancer; 8 months (95%CI 6.1-9.9) for rectal cancer. Low haemoglobin, high platelets and inflammatory markers increased from as early as 9 months pre-diagnosis. Conclusion: Our study found evidence for early increase in rates of consultation for relevant clinical features and abnormal blood tests in patients with colorectal cancer, suggesting that earlier instigation of cancer-specific investigations or referrals may be warranted in some symptomatic patients.
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White B, Renzi C, Rafiq M, Abel GA, Jensen H, Lyratzopoulos G. Does changing healthcare use signal opportunities for earlier detection of cancer? A review of studies using information from electronic patient records. Cancer Epidemiol 2022; 76:102072. [PMID: 34876377 PMCID: PMC8785122 DOI: 10.1016/j.canep.2021.102072] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 11/10/2021] [Accepted: 11/14/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND It has been proposed that changes in healthcare use before cancer diagnosis could signal opportunities for quicker detection, but systematic appreciation of such evidence is lacking. We reviewed studies examining pre-diagnostic changes in healthcare utilisation (e.g. rates of GP or hospital consultations, prescriptions or diagnostic tests) among patients subsequently diagnosed with cancer. METHODS We identified studies through Pubmed searches complemented by expert elicitation. We extracted information on the earliest time point when diagnosis could have been possible for at least some cancers, together with variation in the length of such 'diagnostic windows' by tumour and patient characteristics. RESULTS Across twenty-eight studies, changes in healthcare use were observable at least six months pre-diagnosis for many common cancers, and potentially even earlier for colorectal cancer, multiple myeloma and brain tumours. Early changes were also identified for brain and colon cancer sub-sites. CONCLUSION Changing healthcare utilisation patterns before diagnosis indicate that future improvements in diagnostic technologies or services could help to shorten diagnostic intervals for cancer. There is greatest potential for quicker diagnosis for certain cancer types and patient groups, which can inform priorities for the development of decision support tools.
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Affiliation(s)
- Becky White
- ECHO (Epidemiology of Cancer Healthcare and Outcomes, Department of Behavioural Science and Health, Institute of Epidemiology and Health Care (IEHC)), University College London, Gower Street, London WC1E 6BT, UK.
| | - Cristina Renzi
- ECHO (Epidemiology of Cancer Healthcare and Outcomes, Department of Behavioural Science and Health, Institute of Epidemiology and Health Care (IEHC)), University College London, Gower Street, London WC1E 6BT, UK
| | - Meena Rafiq
- ECHO (Epidemiology of Cancer Healthcare and Outcomes, Department of Behavioural Science and Health, Institute of Epidemiology and Health Care (IEHC)), University College London, Gower Street, London WC1E 6BT, UK
| | - Gary A Abel
- University of Exeter Medical School, St Luke's Campus, Magdalen Road, Exeter EX1 2LU, UK
| | - Henry Jensen
- Research Unit for General Practice, Bartholins Allé 2, 8000 Aarhus C, Denmark
| | - Georgios Lyratzopoulos
- ECHO (Epidemiology of Cancer Healthcare and Outcomes, Department of Behavioural Science and Health, Institute of Epidemiology and Health Care (IEHC)), University College London, Gower Street, London WC1E 6BT, UK
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Abstract
Abdominal pain is the most common chief complaint in the Emergency Department. Abdominal pain is caused by a variety of gastrointestinal and nongastrointestinal disorders. Some frequently missed conditions include biliary pathology, appendicitis, diverticulitis, and urogenital pathology. The Emergency Medicine clinician must consider all aspects of the patient's presentation including history, physical examination, laboratory testing, and imaging. If no diagnosis is identified, close reassessment of pain, vital signs, and physical examination are necessary to ensure safe discharge. Strict verbal and written return precautions should be provided to the patient.
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Affiliation(s)
- Maglin Halsey-Nichols
- University of North Carolina at Chapel Hill, Houpt Building (Physician Office Building) Suite 1116, 170 Manning Drive- CB-7594, Chapel Hill, NC 27599-7594, USA.
| | - Nicole McCoin
- Department of Emergency Medicine, Ochsner Medical Center, 1514 Jefferson Highway, New Orleans, LA 70121, USA
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Zhou Y, Abel GA, Hamilton W, Singh H, Walter FM, Lyratzopoulos G. Imaging activity possibly signalling missed diagnostic opportunities in bladder and kidney cancer: A longitudinal data-linkage study using primary care electronic health records. Cancer Epidemiol 2020; 66:101703. [PMID: 32334389 PMCID: PMC7294227 DOI: 10.1016/j.canep.2020.101703] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 02/13/2020] [Accepted: 03/12/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Sub-optimal use or interpretation of imaging investigations prior to diagnosis of certain cancers may be associated with less timely diagnosis, but pre-diagnostic imaging activity for urological cancer is unknown. METHOD We analysed linked data derived from primary and secondary care records and cancer registration to evaluate the use of clinically relevant imaging tests pre-diagnosis, in patients with bladder and kidney cancer diagnosed in 2012-15 in England. As pre-diagnostic imaging activity increased from background rate 8 months pre-diagnosis, we used logistic regression to determine factors associated with first imaging test occurring 4-8 months pre-diagnosis, considering that such instances may reflect possible missed opportunities for expediting the diagnosis. RESULTS 1963 patients with bladder or kidney cancer had at least one imaging test in the 8 months pre-diagnosis. 420 (21%) of patients had their first imaging test 4-8 months pre-diagnosis, that being ultrasound, CT and X-ray in 48%, 43% and 9% of those cases, respectively. Factors associated with greater risk of a first imaging test 4-8 months pre-diagnosis were kidney cancer, diagnosis at stages other than stage IV, first imaging having been an X-ray, test requested by GP and absence of haematuria before the imaging request. CONCLUSION About 1 in 5 patients with urological cancers receive relevant first imaging investigations 4-8 months prior to diagnosis, which may represent potential missed diagnostic opportunities for earlier diagnosis.
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Affiliation(s)
- Yin Zhou
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK.
| | - Gary A Abel
- College of Medicine and Health, University of Exeter Medical School (Primary Care), Exeter, UK
| | - William Hamilton
- College of Medicine and Health, University of Exeter Medical School (Primary Care), Exeter, UK
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX, USA
| | - Fiona M Walter
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Georgios Lyratzopoulos
- Epidemiology of Cancer Healthcare and Outcomes (ECHO) Research Group, Department of Behavioural Science and Health, University College London, London, UK
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Amelung D, Whitaker KL, Lennard D, Ogden M, Sheringham J, Zhou Y, Walter FM, Singh H, Vincent C, Black G. Influence of doctor-patient conversations on behaviours of patients presenting to primary care with new or persistent symptoms: a video observation study. BMJ Qual Saf 2020; 29:198-208. [PMID: 31326946 PMCID: PMC7057803 DOI: 10.1136/bmjqs-2019-009485] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 07/02/2019] [Accepted: 07/09/2019] [Indexed: 01/03/2023]
Abstract
BACKGROUND Most cancers are diagnosed following contact with primary care. Patients diagnosed with cancer often see their doctor multiple times with potentially relevant symptoms before being referred to see a specialist, suggesting missed opportunities during doctor-patient conversations. OBJECTIVE To understand doctor-patient communication around the significance of persistent or new presenting problems and its potential impact on timely cancer diagnosis. RESEARCH DESIGN Qualitative thematic analysis based on video recordings of doctor-patient consultations in primary care and follow-up interviews with patients and doctors. 80 video observations, 20 patient interviews and 7 doctor interviews across 7 general practices in England. RESULTS We found that timeliness of diagnosis may be adversely affected if doctors and patients do not come to an agreement about the presenting problem's significance. 'Disagreements' may involve misaligned cognitive factors such as differences in medical knowledge between doctor and patient or misaligned emotional factors such as patients' unexpressed fear of diagnostic procedures. Interviews suggested that conversations where the difference in views is either not recognised or stays unresolved may lead to unhelpful patient behaviour after the consultation (eg, non-attendance at specialist appointments), creating potential for diagnostic delay and patient harm. CONCLUSIONS Our findings highlight how doctor-patient consultations can impact timely diagnosis when patients present with persistent or new problems. Misalignments were common and could go unnoticed, leaving gaps for potential to cause patient harm. These findings have implications for timely diagnosis of cancer and other serious disease because they highlight the complexity and fluidity of the consultation and the subsequent impact on the diagnostic process.
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Affiliation(s)
| | | | - Debby Lennard
- Public Involvement Programme (People in Research), National Institute for Health and Care Excellence, London, UK
| | - Margaret Ogden
- Public Involvement Programme (People in Research), National Institute for Health and Care Excellence, London, UK
| | - Jessica Sheringham
- Department of Applied Health Research, University College London, London, UK
| | - Yin Zhou
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Fiona M Walter
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas, USA
| | | | - Georgia Black
- Department of Applied Health Research, University College London, London, UK
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12
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Renzi C, Lyratzopoulos G, Hamilton W, Maringe C, Rachet B. Contrasting effects of comorbidities on emergency colon cancer diagnosis: a longitudinal data-linkage study in England. BMC Health Serv Res 2019; 19:311. [PMID: 31092238 PMCID: PMC6521448 DOI: 10.1186/s12913-019-4075-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 04/08/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND One in three colon cancers are diagnosed as an emergency, which is associated with worse cancer outcomes. Chronic conditions (comorbidities) affect large proportions of adults and they might influence the risk of emergency presentations (EP). METHODS We aimed to evaluate the effect of specific pre-existing comorbidities on the risk of colon cancer being diagnosed following an EP rather than through non-emergency routes. The cohort study included 5745 colon cancer patients diagnosed in England 2005-2010, with individually-linked cancer registry, primary and secondary care data. In addition to multivariable analyses we also used potential-outcomes methods. RESULTS Colon cancer patients with comorbidities consulted their GP more frequently with cancer symptoms during the pre-diagnostic year, compared with non-comorbid cancer patients. EP occurred more frequently in patients with 'serious' or complex comorbidities (diabetes, cardiac and respiratory diseases) diagnosed/treated in hospital during the years pre-cancer diagnosis (43% EP in comorbid versus 27% in non-comorbid individuals; multivariable analysis Odds Ratio (OR), controlling for socio-demographic factors and symptoms: men OR = 2.40; 95% CI 2.0-2.9 and women OR = 1.98; 95% CI 1.6-2.4. Among women younger than 60, gynaecological (OR = 3.41; 95% CI 1.2-9.9) or recent onset gastro-intestinal conditions (OR = 2.84; 95% CI 1.1-7.7) increased the risk of EP. In contrast, primary care visits for hypertension monitoring decreased EPs for both genders. CONCLUSIONS Patients with comorbidities have a greater risk of being diagnosed with cancer as an emergency, although they consult more frequently with cancer symptoms during the year pre-cancer diagnosis. This suggests that comorbidities may interfere with diagnostic reasoning or investigations due to 'competing demands' or because they provide 'alternative explanations'. In contrast, the management of chronic risk factors such as hypertension may offer opportunities for earlier diagnosis. Interventions are needed to support the diagnostic process in comorbid patients. Appropriate guidelines and diagnostic services to support the evaluation of new or changing symptoms in comorbid patients may be useful.
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Affiliation(s)
- Cristina Renzi
- Department of Behavioural Science and Health, ECHO (Epidemiology of Cancer Healthcare & Outcomes) Research Group, University College London, 1-19 Torrington Place, London, WC1E 6BT UK
- Department of Non-communicable Disease Epidemiology, Cancer Survival Group, London School of Hygiene and Tropical Medicine, Keppel St, Bloomsbury, London, WC1E 7HT UK
| | - Georgios Lyratzopoulos
- Department of Behavioural Science and Health, ECHO (Epidemiology of Cancer Healthcare & Outcomes) Research Group, University College London, 1-19 Torrington Place, London, WC1E 6BT UK
| | - Willie Hamilton
- University of Exeter Medical School, St Luke’s Campus, Heavitree Road, Exeter, EX1 2LU UK
| | - Camille Maringe
- Department of Non-communicable Disease Epidemiology, Cancer Survival Group, London School of Hygiene and Tropical Medicine, Keppel St, Bloomsbury, London, WC1E 7HT UK
| | - Bernard Rachet
- Department of Non-communicable Disease Epidemiology, Cancer Survival Group, London School of Hygiene and Tropical Medicine, Keppel St, Bloomsbury, London, WC1E 7HT UK
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Renzi C, Lyratzopoulos G, Hamilton W, Rachet B. Opportunities for reducing emergency diagnoses of colon cancer in women and men: A data-linkage study on pre-diagnostic symptomatic presentations and benign diagnoses. Eur J Cancer Care (Engl) 2019; 28:e13000. [PMID: 30734381 PMCID: PMC6492167 DOI: 10.1111/ecc.13000] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 09/17/2018] [Accepted: 12/18/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To identify opportunities for reducing emergency colon cancer diagnoses, we evaluated symptoms and benign diagnoses recorded before emergency presentations (EP). METHODS Cohort of 5,745 colon cancers diagnosed in England 2005-2010, with individually linked cancer registry and primary care data for the 5-year pre-diagnostic period. RESULTS Colon cancer was diagnosed following EP in 34% of women and 30% of men. Among emergency presenters, 20% of women and 15% of men (p = 0.002) had alarm symptoms (anaemia/rectal bleeding/change in bowel habit) 2-12 months pre-diagnosis. Women with abdominal symptoms (change in bowel habit/constipation/diarrhoea) received a benign diagnosis (irritable bowel syndrome (IBS)/diverticular disease) more frequently than men in the year before EP: 12% vs. 6% among women and men (p = 0.002). EP was more likely in women (OR = 1.20; 95% CI 1.1-1.4), independently of socio-demographic factors and symptoms. Benign diagnoses in the pre-diagnostic year (OR = 2.01; 95% CI 1.2-3.3) and anaemia 2-5 years pre-diagnosis (OR = 1.91; 95% CI 1.2-3.0) increased the risk of EP in women but not men. The risk was particularly high for women aged 40-59 with a recent benign diagnosis vs. none (OR = 4.41; 95% CI 1.3-14.9). CONCLUSIONS Women have an increased risk of EP, in part due to less specific symptoms and their more frequent attribution to benign diagnoses. For women aged 40-59 years with new-onset IBS/diverticular disease innovative diagnostic strategies are needed, which might include use of quantitative faecal haemoglobin testing (FIT) or other colorectal cancer investigations. One-fifth of women had alarm symptoms before EP, offering opportunities for earlier diagnosis.
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Affiliation(s)
- Cristina Renzi
- Department of Behavioural Science and HealthUniversity College LondonLondonUK
- Cancer Survival Group, Department of Non‐communicable Disease EpidemiologyLondon School of Hygiene and Tropical MedicineLondonUK
| | | | | | - Bernard Rachet
- Cancer Survival Group, Department of Non‐communicable Disease EpidemiologyLondon School of Hygiene and Tropical MedicineLondonUK
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14
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Weller D. When cancer is diagnosed as an emergency. Eur J Cancer Care (Engl) 2019; 28:e13035. [DOI: 10.1111/ecc.13035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- David Weller
- Centre for Population Health Sciences; University of Edinburgh; Edinburgh UK
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15
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Maringe C, Rachet B, Lyratzopoulos G, Rubio FJ. Persistent inequalities in unplanned hospitalisation among colon cancer patients across critical phases of their care pathway, England, 2011-13. Br J Cancer 2018; 119:551-557. [PMID: 30108292 PMCID: PMC6162238 DOI: 10.1038/s41416-018-0170-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 06/05/2018] [Accepted: 06/13/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Reducing hospital emergency admissions is a key target for all modern health systems. METHODS We analysed colon cancer patients diagnosed in 2011-13 in England. We screened their individual Hospital Episode Statistics records in the 90 days pre-diagnosis, the 90 days post-diagnosis, and the 90 days pre-death (in the year following diagnosis), for the occurrence of hospital emergency admissions (HEAs). RESULTS Between a quarter and two thirds of patients experience HEA in the three 90-day periods examined: pre-diagnosis, post-diagnosis and before death. Patients with tumour stage I-III from more deprived backgrounds had higher proportions of HEAs than less deprived patients during all studied periods. This remains even after adjusting for differing distributions of risk factors such as age, sex, comorbidity and stage at diagnosis. CONCLUSIONS Although in some cases HEAs might be unavoidable or even appropriate, the proportion of HEAs varies by socioeconomic status, even after controlling for the usual patient factors, suggestive of remediable causes of excess emergency healthcare utilisation in patients belonging to higher deprivation groups. Future inquiries should address the potential role of clinical complications, sub-optimal healthcare administration, premature discharge or a lack of social support as potential explanations for these patterns of inequality.
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Affiliation(s)
- Camille Maringe
- Cancer Survival Group, Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Bernard Rachet
- Cancer Survival Group, Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Georgios Lyratzopoulos
- Epidemiology of Cancer Healthcare and Outcomes (ECHO) Research Group, Department of Behavioural Science and Health, University College London, London, WC1E 7HB, UK
| | - Francisco Javier Rubio
- Cancer Survival Group, Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK.
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