Patient delay in cancer diagnosis: what do we really mean and can we be more specific?

Neural Circuitries between the Brain and Peripheral Solid Tumors

The recent discovery of the pivotal role of the central nervous system in controlling tumor initiation and progression has opened a new field of research. Increasing evidence suggests a bidirectional interaction between the brain and tumors. The brain influences the biological behavior of tumor cells through complex neural networks involving the peripheral nervous system, the endocrine system, and the immune system, whereas tumors can establish local autonomic and sensory neural networks to transmit signals into the central nervous system, thereby affecting brain activity. This review aims to summarize the latest research in brain-tumor cross-talk, exploring neural circuitries between the brain and various peripheral solid tumors, analyzing the roles in tumor development and the related molecular mediators and pathologic mechanisms, and highlighting the critical impact on the understanding of cancer biology. Enhanced understanding of reciprocal communication between the brain and tumors will establish a solid theoretical basis for further research and could open avenues for repurposing psychiatric interventions in cancer treatment.

Exploring Information Seeking Anxiety Among Localized Prostate Cancer Patients

Information seeking anxiety is a multidimensional construct that is operationalized as having elements of worry, confusion, and disorganization. Much remains unknown about the ways information seeking anxiety operates among cancer patients in the United States. This study investigated the application of the information seeking anxiety concept among prostate cancer patients by documenting their assessment experiences and examining relationships between information seeking anxiety and treatment information search behaviors. A purposive sample of African American and Caucasian men (N = 63) within 5 years of being diagnosed with localized disease (stage T1 or T2) were recruited to participate through cancer registries, advertisements, and word-of-mouth. Participants completed a self-administered survey with items that collected demographic information, treatment information-seeking behaviors, and information seeking anxiety evaluations. All surveys were completed in one sitting and a majority of men (82.5%, N = 52) completed the information seeking anxiety assessment with no assistance. During their first interactions with available sources of information (e.g., doctors, internet, peers), most survivors (95.2%, N = 60) reported some level of information seeking anxiety. Specifically, 55.5% (N = 35) were confused about what to look for, 60.3% (N = 38) were worried they would not find the right information, 55.5% (N = 35) were uncomfortable with the search process, and 49.2% (N = 31) reported being disorganized. The composite information seeking anxiety measure was moderately correlated with men's self-reported time to start searching for treatment information (p = .02; r = .306). Information seeking anxiety appears to delay the treatment information gathering activities of prostate cancer survivors with localized disease. This previously undocumented barrier to the delivery of prostate cancer care services should be investigated in other studies with larger and more diverse samples.

Being the nurse for my child at home: A qualitative analysis of parental recognition, appraisal, and reactions to childhood cancer in Ghana

Parental involvement in childhood cancer care is of utmost importance, but the understanding of parental recognition, appraisal, and reactions to childhood cancer in settings such as Ghana is limited. We conducted an empirical phenomenological study to explore these aspects among Ghanaian parents. Twenty parents were purposively sampled to participate in semi-structured interviews between June and September 2022. All interviews were transcribed and analysed using an inductive thematic approach. We found that parents recognised symptoms through personal observation and their child's self-report, often perceiving them as non-severe. Emotional reactions upon receiving their child's cancer diagnosis included psychological distress, fear, doubts, and confusion. Enduring emotions experienced by parents were fears of disease recurrence and impending death of their child. Parents assumed the role of nurses at home, monitoring therapy effects, managing pain and symptoms, and dressing wounds. In conclusion, parents in Ghana play a crucial role in the recognition, diagnosis, and treatment pathways of childhood cancer. To enhance their ability to recognise symptoms and take timely actions, it is recommended to implement media programs and health education initiatives targeting parents.

Normal or diseased? Navigating indeterminate gut behaviour

Introduction Delayed diagnosis of gut disease is a continuing problem, variously attributed to a range of patient, doctor, and health system factors. Gut disease often begins with indeterminate gut behaviours that are hard to classify. Aim This study aimed to investigate delayed diagnosis from the point of view of the patient, or prospective patient. How gut and gut disease was understood, what might prompt them to seek care, and their experiences of seeking care. Methods Using a qualitative design, we interviewed 44 people in New Zealand. Thirty-three had a diagnosis of gut disease, and 11 did not, though some of the patients in this latter group had symptoms. Results Some participants had a smooth trajectory from first noticing gut symptoms to diagnosis. However, a subgroup of 22 participants experienced long periods of troublesome gut behaviours without a diagnosis. For this subgroup of 22 participants, we found people struggled to work out what was normal, thus influencing when they sought health care. Once they sought health care, experiences of that care could be frustrating, and achieving a diagnosis protracted. Some who remained undiagnosed felt abandoned, though had developed strategies to self-manage. Discussion Indeterminate gut behaviours remain complex to deal with and it can difficult for both patients and doctors to assess when a symptom or group of symptoms need further investigation, watchful waiting or the use of other supportive strategies. Effectively communicating with healthcare staff can be a significant problem and there is currently a gap in support for patients in this regard.

3D Printing for Cancer Diagnosis: What Unique Advantages Are Gained?

Cancer is a complex disease with global significance, necessitating continuous advancements in diagnostics and treatment. 3D printing technology has emerged as a revolutionary tool in cancer diagnostics, offering immense potential in detection and monitoring. Traditional diagnostic methods have limitations in providing molecular and genetic tumor information that is crucial for personalized treatment decisions. Biomarkers have become invaluable in cancer diagnostics, but their detection often requires specialized facilities and resources. 3D printing technology enables the fabrication of customized sensor arrays, enhancing the detection of multiple biomarkers specific to different types of cancer. These 3D-printed arrays offer improved sensitivity, allowing the detection of low levels of biomarkers, even in complex samples. Moreover, their specificity can be fine-tuned, reducing false-positive and false-negative results. The streamlined and cost-effective fabrication process of 3D printing makes these sensor arrays accessible, potentially improving cancer diagnostics on a global scale. By harnessing 3D printing, researchers and clinicians can enhance early detection, monitor treatment response, and improve patient outcomes. The integration of 3D printing in cancer diagnostics holds significant promise for the future of personalized cancer care.

Can Oncologists Prompt Patient Prognostic Awareness to Enhance Decision-Making? Data From the NEOetic Study

INTRODUCTION

Anti-neoplastic therapy improves the prognosis for advanced cancer, albeit it is not curative. An ethical dilemma that often arises during patients' first appointment with the oncologist is to give them only the prognostic information they can tolerate, even at the cost of compromising preference-based decision-making, versus giving them full information to force prompt prognostic awareness, at the risk of causing psychological harm.

METHODS

We recruited 550 participants with advanced cancer. After the appointment, patients and clinicians completed several questionnaires about preferences, expectations, prognostic awareness, hope, psychological symptoms, and other treatment-related aspects. The aim was to characterize the prevalence, explanatory factors, and consequences of inaccurate prognostic awareness and interest in therapy.

RESULTS

Inaccurate prognostic awareness affected 74%, conditioned by the administration of vague information without alluding to death (odds ratio [OR] 2.54; 95% CI, 1.47-4.37, adjusted P = .006). A full 68% agreed to low-efficacy therapies. Ethical and psychological factors oriented first-line decision-making, in a trade-off in which some lose quality of life and mood, for others to gain autonomy. Imprecise prognostic awareness was associated with greater interest in low-efficacy treatments (OR 2.27; 95% CI, 1.31-3.84; adjusted P = .017), whereas realistic understanding increased anxiety (OR 1.63; 95% CI, 1.01-2.65; adjusted P = 0.038), depression (OR 1.96; 95% CI, 1.23-3.11; adjusted P = .020), and diminished quality of life (OR 0.47; 95% CI, 0.29-0.75; adjusted P = .011).

CONCLUSION

In the age of immunotherapy and targeted therapies, many appear not to understand that antineoplastic therapy is not curative. Within the mix of inputs that comprise inaccurate prognostic awareness, many psychosocial factors are as relevant as the physicians' disclosure of information. Thus, the desire for better decision-making can actually harm the patient.

Recognising symptoms of congenital myasthenic syndromes in children: A guide for paediatricians

AIM

Congenital myasthenic syndromes (CMS) are a rare and diverse group of treatable neuromuscular transmission disorders. Diagnosis is often substantially delayed. This study aimed to identify common symptoms of CMS in children and their manifestation to aid diagnosis and early intervention.

METHODS

We performed a retrospective cohort study, including 18 children (median age 13 years, range 9 years 5 months-18 years 0 month) with CMS. Data on CMS symptoms and their manifestation were extracted from patients' charts and supplemented with parental telephone interviews. Descriptive analyses were used to identify common symptoms.

RESULTS

A median diagnostic delay of 4 years and 7 months (interquartile range: 51 months) was observed. Proximal muscle weakness (100%), ptosis (89%), clumsy gait (82%), difficulty eating solid foods (78%) and recurrent respiratory tract infections (72%) were most common in these patients. Symptoms mostly co-occurred and frequently had a fluctuating character, aggravated by infections or fatigue.

CONCLUSION

Early referral to diagnose CMS is crucial to enable timely initiation of treatment. Heightened attention to a combination of symptoms related to muscle weakness, rather than individual symptoms, should support paediatricians in flagging these neuromuscular disorders. Medical history taking should be tailored to parents' perceptions, asking questions about recognisable symptoms of muscle weakness.

National Cancer Diagnosis Audits for England 2018 versus 2014: a comparative analysis

BACKGROUND

Timely diagnosis of cancer in patients who present with symptoms in primary care is a quality-improvement priority.

AIM

To examine possible changes to aspects of the diagnostic process, and its timeliness, before and after publication of the National Institute for Health and Care Excellence's (2015) guidance on the referral of suspected cancer in primary care.

DESIGN AND SETTING

Comparison of findings from population-based clinical audits of cancer diagnosis in general practices in England for patients diagnosed in 2018 or 2014.

METHOD

GPs in 1878 (2018) and 439 (2014) practices collected primary care information on the diagnostic pathway of cancer patients. Key measures including patient characteristics, place of presentation, number of pre-referral consultations, use of primary care investigations, and referral type were compared between the two audits by descriptive analysis and regression models.

RESULTS

Among 64 489 (2018) and 17 042 (2014) records of a new cancer diagnosis, the percentage of patients with same-day referral (denoted by a primary care interval of 0 days) was higher in 2018 (42.7% versus 37.7%) than in 2014, with similar improvements in median diagnostic interval (36 days versus 40 days). Compared with 2014, in 2018: fewer patients had ≥3 pre-referral consultations (18.8% versus 26.2%); use of primary care investigations increased (47.9% versus 45.4%); urgent cancer referrals increased (54.8% versus 51.8%); emergency referrals decreased (13.4% versus 16.5%); and recorded use of safety netting decreased (40.0% versus 44.4%).

CONCLUSION

In the 5-year period, including the year when national guidelines were updated (that is, 2015), there were substantial improvements to the diagnostic process of patients who present to general practice in England with symptoms of a subsequently diagnosed cancer.

Socioeconomic status and cancer survival in Brazil: Analysis of population data from the municipalities of Aracaju and Curitiba, 1996-2012

INTRODUCTION

The association between socioeconomic status and cancer prognosis has been demonstrated in several countries. Despite the existence of indirect evidence of this phenomenon in Brazil, few studies in this regard are available.

OBJECTIVES

The objective of the present study is to analyse socioeconomic related survival gaps for patients diagnosed with breast, cervical, lung, prostate, and colorectal cancer in the cities of Aracaju (SE) and Curitiba (PR).

METHODS

Using population-based data, we estimated net survival by tumour site, year of diagnosis, socioeconomic status and local of residence. Net survival estimation was done with multilevel parametric model allowing flexible spline functions do estimate excess mortality hazards.

RESULTS

28,005 cases were included in survival analysis. Five-year net survival showed positive association with SES. Intermunicipal survival gaps favouring Aracaju where prominent for breast (reaching 16,1% in 5 years) OBJECTIVES: Study the impact of socioeconomic factors on cancer survival in two Brazilian capitals.

METHODS

Survival analysis using population-based cancer data including patients diagnosed with breast, lung, prostate, cervical and colorectal cancer between 1996 and 2012 in Aracaju and Curitiba. Outcomes were excessive mortality hazard (EMH) and 5- and 8-years net survival (NS). The association of race/skin color and socioeconomic level (SES) with EMH and net survival were analyzed using a multilevel regression model with flexible splines.

RESULTS

28,005 cases were included, 6636 from Aracaju and 21,369 from Curitiba. NS for all diseases studied increased more prominently for Curitiba population. We observed NS gap between the populations of Aracaju and Curitiba that increased or remained stable during the study period, with emphasis on the growth of the difference in NS of lung and colon cancer (among men). Only for cervical cancer and prostate cancer there was a reduction in the intermunicipal gaps. 5-year NS for breast cancer in Aracaju ranged from 55.2% to 73.4% according to SES. In Curitiba this variation was from 66.5% to 83.8%.

CONCLUSION

The results of the present study suggests widening of socioeconomic and regional inequalities in the survival of patients with colorectal, breast, cervical, lung and prostate cancers in Brazil during the 1990 s and 2000 s.

Insights into the Impact of Hesitancy on Cancer Care and COVID-19

World Health Organization findings indicate that the COVID-19 pandemic adversely affected cancer diagnosis and management. The COVID-19 pandemic disrupted the optimal management of outpatient appointments, scheduled treatments, and hospitalizations for cancer patients because of hesitancy among patients and health-care providers. Travel restrictions and other factors likely affected medical, surgical, and radiation treatments during the COVID-19 pandemic. Cancer patients were more likely to be affected by severe illness and complications if they contracted COVID-19. A compromised immune system and comorbidities in cancer patients may have contributed to this increased risk. Hesitancy or reluctance to receive appropriate therapy or vaccination advice might have played a major role for cancer patients, resulting in health-care deficits. The purpose of this review is to evaluate the impact of COVID-19 on screening, entry into clinical trials, and hesitancy among patients and health-care professionals, limiting adjuvant and metastatic cancer treatment.

Physical and mental health of breast cancer patients and survivors before and during successive SARS-CoV-2-infection waves

PURPOSE

During the first SARS-CoV-2-infection wave, a deterioration in emotional well-being and increased need for mental health care were observed among patients treated or being treated for breast cancer. In this follow-up study, we assessed patient-reported quality of life (QoL), physical functioning, and psychosocial well-being during the second SARS-CoV-2-infection wave in a large, representative cohort.

METHODS

This longitudinal cohort study was conducted within the prospective, multicenter UMBRELLA breast cancer cohort. To assess patient-reported QoL, physical functioning and psychosocial well-being, COVID-19-specific surveys were completed by patients during the first and second SARS-CoV-2-infection waves (April and November 2020, respectively). An identical survey was completed by a comparable reference population during the second SARS-CoV-2-infection waves. All surveys included the validated EORTC-QLQ-C30/BR23, HADS and "De Jong-Gierveld Loneliness" questionnaires. Pre-COVID-19 EORTC-QLQ-C30/BR23 and HADS outcomes were available from UMBRELLA. Response rates were 69.3% (n = 1106/1595) during the first SARS-CoV-2-infection wave and 50.9% (n = 822/1614) during the second wave. A total of 696 patients responded during both SARS-CoV-2-infection waves and were included in the analysis comparing patient-reported outcomes (PROs) during the second SARS-CoV-2-infection wave to PROs during the first wave. Moreover, PROs reported by all patients during the second SARS-CoV-2-infection wave (n = 822) were compared to PROs of a similar non-cancer reference population (n = 241) and to their pre-COVID-19 PROs.

RESULTS

Patient-reported QoL, physical functioning, and psychosocial well-being of patients treated or being treated for breast cancer remained stable or improved from the first to the second SARS-CoV-2-infection wave. The proportion of emotional loneliness reduced from 37.6 to 29.9% of patients. Compared to a similar non-cancer reference population, physical, emotional, and cognitive functioning, future perspectives and symptoms of dyspnea and insomnia were worse in patients treated or being treated for breast cancer during the second SARS-CoV-2-infection wave. PROs in the second wave were similar to pre-COVID-19 PROs.

CONCLUSION

Although patients scored overall worse than individuals without breast cancer, QoL, physical functioning, and psychosocial well-being did not deteriorate between the first and second wave. During the second wave, PROs were similar to pre-COVID-19 values. Overall, current findings are cautiously reassuring for future mental health of patients treated or being treated for breast cancer.

"I have travelled along on my own"-Experiences of seeking help for serious non-COVID health problems during the COVID-19 pandemic: A qualitative study

OBJECTIVES

During COVID-19 the UK general population has been given strong messages to stay at home. Concurrently unprecedented changes occurred in healthcare access with moves to remote/triage systems. Data have shown that the number of people accessing healthcare services decreased and there are significant concerns that the pandemic has negatively affected help-seeking for serious conditions, with potentially increased morbidity and mortality. An understanding of help-seeking is urgently needed to inform public campaigns. We aimed to develop an in-depth, theory-based understanding of how, when and why people sought help for potentially serious symptoms (e.g., related to major cardiovascular events or cancer diagnoses) during the pandemic, and what influenced their decisions.

DESIGN

Qualitative semi-structured interviews.

METHODS

We interviewed 25 adults recruited through a targeted social media campaign. Interviews were conducted via telephone or online platform. Our topic guide was informed by the Model of Pathways to Treatment and the Capability-Opportunity-Motivation-Behaviour model.

RESULTS

The analysis identified four main themes: Delay in recognition, Holding on to concerns, Weighing it up and Long-term impacts. Multiple societal and environmental factors influenced participants' help-seeking and motivation, capability and opportunity to seek help, with long-term impacts on well-being and future help-seeking.

CONCLUSIONS

There is a need for clear guidance about pathways to raise concerns about symptoms and gain advice while usual healthcare contacts are paused or stopped. Recommendations for future interventions to support help-seeking during pandemics include clearer messaging, co-produced with end-users, on when, where and how to seek help.

Timeliness of diagnosis and treatment: the challenge of childhood cancers

Cancer represents an important cause of disease-related death in children worldwide. Improved treatment and understanding of the ways in which cancer manifests has allowed for a greater prospect of survival in children of all ages. However, variation in childhood cancer experience exists based on factors at the individual, community and systems levels. Throughout the cancer care continuum these factors may influence the access and timeliness of care a child receives, leading to delays in diagnosis and treatment. The pejorative designation 'delay in diagnosis and treatment' is better characterised as lag time, representing an interval that is thought to influence survival and overall outcome. In recent decades, work has been done to expedite early childhood cancer diagnosis through the creation of screening and education-based programmes. Although systematic cancer screening in children poses risks and fails to achieve the goal of early diagnosis, a case has been made for risk-based surveillance that has been shown to improve outcome and reduce occurrence of advanced stage disease in targeted populations. The components of lag time are examined separately and individually. This review highlights the challenges of early diagnosis in childhood cancers and describes important contributors in the cancer care continuum.

Blood-Based Multi-Cancer Detection Using a Novel Variant Calling Assay (DEEPGENTM): Early Clinical Results

This is an early clinical analysis of the DEEPGENTM platform for cancer detection. Newly diagnosed cancer patients and individuals with no known malignancy were included in a prospective open-label case-controlled study (NCT03517332). Plasma cfDNA that was extracted from peripheral blood was sequenced and data were processed using machine-learning algorithms to derive cancer prediction scores. A total of 260 cancer patients and 415 controls were included in the study. Overall, sensitivity for all cancers was 57% (95% CI: 52, 64) at 95% specificity, and 43% (95% CI: 37, 49) at 99% specificity. With 51% sensitivity and 95% specificity for all stage 1 cancers, the stage-specific sensitivities trended to improve with higher stages. Early results from this preliminary clinical, prospective evaluation of the DEEPGENTM liquid biopsy platform suggests the platform offers a clinically relevant ability to differentiate individuals with and without known cancer, even at early stages of cancer.

Diagnostic and Therapeutic Delays in Patients With Hepatocellular Carcinoma

BACKGROUND

Delays in diagnosis and treatment have been reported for many cancers, with resultant stage migration and worse survival; however, few data exist in patients with hepatocellular carcinoma (HCC). These data are of particular importance in light of the COVID-19 pandemic, which has caused disruptions in healthcare processes and may continue to impact cancer care for the foreseeable future. The aim of our study was to characterize the prevalence and clinical significance of diagnostic and treatment delays in patients with HCC.

METHODS

We performed a retrospective cohort study of consecutive patients diagnosed with HCC between January 2008 and July 2017 at 2 US health systems. Diagnostic and treatment delays were defined as >90 days between presentation and HCC diagnosis and between diagnosis and treatment, respectively. We used multivariable logistic regression to identify factors associated with diagnostic and treatment delays and Cox proportional hazard models to identify correlates of overall survival.

RESULTS

Of 925 patients with HCC, 39.0% were diagnosed via screening, 33.1% incidentally, and 27.9% symptomatically. Median time from presentation to diagnosis was 37 days (interquartile range, 18-94 days), with 120 patients (13.0%) experiencing diagnostic delays. Median time from HCC diagnosis to treatment was 46 days (interquartile range, 29-74 days), with 17.2% of patients experiencing treatment delays. Most (72.5%) diagnostic delays were related to provider-level factors (eg, monitoring indeterminate nodules), whereas nearly half (46.2%) of treatment delays were related to patient-related factors (eg, missed appointments). In multivariable analyses, treatment delays were not associated with increased mortality (hazard ratio, 0.90; 95% CI, 0.60-1.35); these results were consistent across subgroup analyses by Barcelona Clinic Liver Cancer stage and treatment modality.

CONCLUSIONS

Diagnostic and therapeutic delays exceeding 3 months are common in patients with HCC; however, observed treatment delays do not seem to significantly impact overall survival.

Impact of the COVID-19 pandemic and related control measures on cancer diagnosis in Catalonia: a time-series analysis of primary care electronic health records covering about five million people

OBJECTIVE

Cancer care has been disrupted by the response of health systems to the COVID-19 pandemic, especially during lockdowns. The objective of our study is to evaluate the impact of the pandemic on the incidence of cancer diagnoses in primary care.

DESIGN

Time-series study of malignant neoplasms and diagnostic procedures, using data from the primary care electronic health records from January 2014 to September 2020.

SETTING

Primary care, Catalonia, Spain.

PARTICIPANTS

People older than 14 years and assigned in one of the primary care practices of the Catalan Institute of Health with a new diagnosis of malignant neoplasm.

MAIN OUTCOME MEASURES

We obtained the monthly expected incidence of malignant neoplasms using a temporary regression, where the response variable was the incidence of cancer from 2014 to 2018 and the adjustment variables were the trend and seasonality of the time series. Excess or lack of malignant neoplasms was defined as the number of observed minus expected cases, globally and stratified by sex, age, type of cancer and socioeconomic status.

RESULTS

Between March and September 2020 we observed 8766 (95% CI 4135 to 13 397) fewer malignant neoplasm diagnoses, representing a reduction of 34% (95% CI 19.5% to 44.1%) compared with the expected. This underdiagnosis was greater in individuals aged older than 64 years, men and in some types of cancers (skin, colorectal, prostate). Although the reduction was predominantly focused during the lockdown, expected figures have not yet been reached (40.5% reduction during the lockdown and 24.3% reduction after that).

CONCLUSIONS

Reduction in cancer incidence has been observed during and after the lockdown. Urgent policy interventions are necessary to mitigate the indirect effects of the COVID-19 pandemic and related control measures on other diseases and some strategies must be designed in order to reduce the underdiagnosis of cancer.

Symptom Perceptions and Help-Seeking Behaviours of Omani Patients Diagnosed with Late-Stage Colorectal Cancer: A Qualitative Study

OBJECTIVE

Colorectal cancer (CRC) is the fourth leading cause of mortality in Oman, with most patients diagnosed at advanced stages. Early diagnosis of CRC improves prognosis and survival rate. The aim of this study was to explore the symptom perceptions and help-seeking behaviours (HSBs) of Omani patients diagnosed with late-stage CRC.

METHODS

Semi-structured individual interviews were conducted with 16 patients.

RESULTS

Four main themes emerged, including normalisation and ignorance (patients felt healthy, perceived symptoms as not being serious and related to dietary habits, concealed them or prioritised work and family commitments), self-empowerment and self-management (patients were stubborn, employed 'wait and see' approach, used symptomatic or herbal treatments), disclosure and seeking help (patients disclosed symptoms to family members or friends, sought medical help only when symptoms worsened, visited faith healers or travelled abroad for treatment) and healthcare professionals (patients attributed treatment or diagnosis delays to lack of continuity of care, loss of trust in doctors or delays in referral).

CONCLUSION

Patients attributed delays in CRC diagnosis to several factors based on their perceptions of symptoms. Most HSBs driven by sociocultural and emotional causes. Increased awareness of CRC symptoms and modifying HSBs can encourage early diagnosis. Prompting patients to disclose CRC-related symptoms may aid referral decisions.

Parent's perspectives of the pathway to diagnosis of childhood cancer: a matter of diagnostic triage

BACKGROUND

Early diagnosis is crucial for the treatment of childhood cancer as it in some cases can prevent progression of disease and improve prognoses. However, childhood cancer can be difficult to diagnose and barriers to early diagnosis are multifactorial. New knowledge about factors influencing the pathway to diagnosis contribute to a deeper understanding of the mechanisms that influence this time span. Qualitative research in the field is sparse but can be expected to lead to additional useful insights that could contribute to efforts shorten time to diagnosis. The purpose of this study was to explore parents' experiences of the pathway to diagnosis in the time between their noticing bodily or behavioural changes and their child's diagnosis.

METHODS

The study is a qualitative interview study carried out in large Danish hospital. Thirty-two interviews with a total of 46 parents of children with cancer were included for analysis. The children were diagnosed with haematological cancers (n = 17), solid tumours (n = 9) or brain tumours (n = 6). Data were analysed applying the theoretical model of pathways to treatment and an inductive-deductive approach. A revised 'diagnostic triage' model was developed and validated by member checking.

RESULTS

The pathway to diagnosis was influenced by various factors which we present as consistent parts of a new diagnostic triage model. Each factor impacts the level of urgency assigned to bodily and behavioural changes by parents, general practitioners and specialists. The model of diagnostic triage was developed and validated to understand mechanisms influencing time from the point parents notice changes in their child to diagnosis. The model identifies dynamic movement between parental triage in everyday life and professional triage in a healthcare system, both affecting appraisal and case escalation according to: 1) the nature of bodily and behavioural changes, 2) parental intuition, 3) social relations, 4) professional-child-parent interaction, and 5) specialist-child-parent interaction.

CONCLUSIONS

Diagnostic triage is a model which explains mechanisms that shape the pathway to diagnosis. It is a contribution aimed at supporting the clinical diagnostic process, that ultimately could ensure more timely testing, referral and diagnosis, and also a novel theoretical framework for future research on diagnostic pathways.

Evaluation of medical practices in oncology in the context of the COVID-19 pandemic in France: Physicians' point of view: the PRATICOVID study

The cancer population seems to be more susceptible to COVID‐19 infection and have worse outcomes. We had to adapt our medical practice to protect our patients without compromising their cancer prognosis. The national PRATICOVID study aims to describe the adaptation of cancer patient care for this population. We analyzed data from nine different institutions. The primary endpoint was to assess the prevalence of adapted patient care during the pandemic. The secondary endpoints were to describe the point of view of clinicians and patients during and after the pandemic. We analyzed 435 medical procedures between 9^th of March and 30^th of April. Because of the COVID‐19 pandemic, 47.6% of the outpatients received modified patient care. Twenty‐four percent of scheduled surgeries were postponed, or were performed without perioperative chemotherapy, 18.4% followed a hypofractioned schedule, and 57% had an adaptive systemic protocol (stopped, oral protocol, and spacing between treatments). Seventy percent of physicians used telemedicine. During this period, 67% of the physicians did not feel distressed taking care of their patients. However, 70% of physicians are worried about the aftermath of the lockdown, as regards future patient care. The PRATICOVID study is the first to assess modification of patient care in cancer outpatients during an epidemic. With this unprecedented crisis, physicians were able to adapt their practice in order to protect their patients against the virus while ensuring continuity of patient care. But physicians are worried about the aftereffects of the lockdown specifically in regard to care pathway issues.

Co-consumption of Vegetables and Fruit, Whole Grains, and Fiber Reduces the Cancer Risk of Red and Processed Meat in a Large Prospective Cohort of Adults from Alberta's Tomorrow Project

We examined whether co-consumption of red and processed meat with key foods items and food constituents recommended for cancer prevention (vegetables and fruit, whole grains, and fiber) mitigates cancer incidence. In a prospective cohort of 26,218 adults aged 35–69 years at baseline, dietary intake was collected through 124-item past-year food frequency questionnaire. Incidence of all-cause and 15 cancers previously linked to red and processed meat intake was obtained through data linkage with a cancer registry (average follow-up 13.5 years). Competing risk Cox Proportional Hazard models estimated cancer risk and Accelerated Failure Time models estimated time-to-cancer occurrence for different combinations of intake levels while considering mortality from vital statistics and established confounders. Co-consumption of low vegetables and fruit intake with high processed meat was associated with higher incidence of all-cause and 15 cancers (men: HR = 1.85, 1.91; women: HR = 1.44, 1.49) and accelerated time-to-cancer occurrence (men: 6.5 and 7.1 years and women: 5.6 and 6.3 years, respectively), compared to high vegetables and fruit with low processed meat intake. Less pronounced and less consistent associations were observed for whole grains and fiber and for red meat. The findings provide initial evidence toward refining existing cancer prevention recommendations to optimize the intake and combination of foods in the general adult population.

Presentation intervals and the impact of delay on breast cancer progression in a black African population

Background

The help-seeking interval and primary-care interval are points of delays in breast cancer presentation. To inform future intervention targeting early diagnosis of breast cancer, we described the contribution of each interval to the delay and the impact of delay on tumor progression.

Method

We conducted a multicentered survey from June 2017 to May 2018 hypothesizing that most patients visited the first healthcare provider within 60 days of tumor detection. Inferential statistics were by t-test, chi-square test, and Wilcoxon-Signed Rank test at p-value 0.05 or 95% confidence limits. Time-to-event was by survival method. Multivariate analysis was by logistic regression.

Results

Respondents were females between 24 and 95 years (n = 420). Most respondents visited FHP within 60 days of detecting symptoms (230 (60, 95% CI 53–63). Most had long primary-care (237 of 377 (64 95% CI 59–68) and detection-to-specialist (293 (73% (95% CI 68–77)) intervals. The primary care interval (median 106 days, IQR 13–337) was longer than the help-seeking interval (median 42 days, IQR 7–150) Wilcoxon signed-rank test p = 0.001. There was a strong correlation between the length of primary care interval and the detection-to-specialist interval (r = 0.9, 95% CI 0.88–0.92). Patronizing the hospital, receiving the correct advice, and having a big tumor (> 5 cm) were associated with short intervals.

Tumors were detected early, but most became advanced before arriving at the specialist clinic. The difference in tumor size between detection and arriving at a specialist clinic was 5.0 ± 4.9 cm (95% CI 4.0–5.0). The hazard of progressing from early to locally advanced disease was least in the first 30 days (3%). The hazard was 31% in 90 days.

Conclusion

Most respondents presented early to the first healthcare provider, but most arrived late at a specialist clinic. The primary care interval was longer than the help-seeking interval. Most tumors were early at detection but locally advanced before arriving in a specialist clinic. Interventions aiming to shorten the primary care interval will have the most impact on time to breast cancer presentation for specialist oncology care in Nigeria.

Prevalence of Themes Linked to Delayed Presentation of Breast Cancer in Africa: A Meta-Analysis of Patient-Reported Studies

PURPOSE

The prevalence of themes linked to delay in presentation of breast cancer (BC) and their underlying factors vary considerably throughout Africa. Regional differences and trends are largely unreported. The purpose of this research was to provide summary estimates of the prevalence and distribution of the themes and underlying factors linked to delay in the presentation of BC, regional variation, and trends in an effort to identify targets for intervention.

DESIGN

We screened articles found through PubMed/Medline, African Journal OnLine, Science Direct, Google/Google Scholar, and ResearchGate. We included patient-reported surveys on the reasons linked to delayed presentation under 6 previously identified themes: symptom misinterpretation, fear, preference for alternative care, social influence, hospital-related factors, and access factors. The meta-analytical procedure in MetaXL used the quality-effect model.

RESULTS

Twelve of the 236 identified articles were eligible for this review. The overall summary estimate of late presentation (> 90 days) was 54% (95% CI, 23 to 85) and was worst in the eastern and central regions. Symptom misinterpretation was the most common theme (50%; 95% CI, 21 to 56), followed by fear (17%; 95% CI, 3 to 27), hospital-related theme (11%; 95% CI, 1 to 21), preference for alternative care (10%; 95% CI, 0 to 21), social influence (7%; 95% CI, 0 to 14), and access-related theme (6%; 95% CI, 0 to 13). The most common factor underlying symptom misinterpretation was mischaracterizing the breast lesion as benign (60%; 95% CI, 4 to 100) which surpassed lack of awareness in the last decade. Misdiagnosis and failure to refer were the dominant hospital-related factors.

CONCLUSION

Modifiable factors such as mischaracterizing malignant masses as benign, fear, misdiagnosis, and failure to refer were the prevalent factors contributing to delays throughout Africa. These factors are promising targets for intervention.

The frequency, nature and impact of GP-assessed avoidable delays in a population-based cohort of cancer patients

BACKGROUND

There is a growing emphasis on the speed of diagnosis as an aspect of cancer prognosis. While epidemiological data in the last decade have quantified diagnostic timeliness and its variation, whether and how often prolonged diagnostic intervals can be considered avoidable is unknown.

METHODS

We used data from the English National Cancer Diagnosis Audit (NCDA) on 17,042 patients diagnosed with cancer in 2014. Participating primary care physicians were asked to identify delays in diagnosis that they deemed avoidable, together with the 'setting' of the avoidable delay and key attributable factors. We used descriptive analysis and regression frameworks to assess validity and examine variation in the frequency and nature of avoidable delays.

RESULTS

Among 14,259 patients, 24% were deemed to have had an avoidable delay to their diagnosis. Patients with a reported avoidable delay had a longer median diagnostic interval (92 days) than those without (30 days). Of all avoidable delays, 13% were deemed to have occurred pre-consultation, 49% within primary care, and 38% within secondary care. Avoidable delays were mostly attributed to the test request/performance phase (25%). Multimorbidity was associated with greater odds of avoidable delay (OR for 3+ vs no comorbidity: 1.43 (95% CI 1.25-1.63)), with heterogeneous associations with cancer site.

CONCLUSION

We have shown that GP-identified instances of avoidable delay have construct validity. Whilst the causes of avoidable diagnostic delays are multi-factorial and occur in different settings and phases of the diagnostic process, their analysis can guide improvement initiatives and enable the examination of any prognostic implications.

Perceived discrimination, trust in physicians, and prolonged symptom duration before ovarian cancer diagnosis in the African American Cancer Epidemiology Study

BACKGROUND

Discrimination and trust are known barriers to accessing health care. Despite well-documented racial disparities in the ovarian cancer care continuum, the role of these barriers has not been examined. This study evaluated the association of everyday discrimination and trust in physicians with a prolonged interval between symptom onset and ovarian cancer diagnosis (hereafter referred to as prolonged symptom duration).

METHODS

Subjects included cases enrolled in the African American Cancer Epidemiology Study, a multisite case-control study of epithelial ovarian cancer among black women. Logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) for associations of everyday discrimination and trust in physicians with a prolonged symptom duration (1 or more symptoms lasting longer than the median symptom-specific duration), and it controlled for access-to-care covariates and potential confounders.

RESULTS

Among the 486 cases in this analysis, 302 women had prolonged symptom duration. In the fully adjusted model, a 1-unit increase in the frequency of everyday discrimination increased the odds of prolonged symptom duration 74% (OR, 1.74; 95% CI, 1.22-2.49), but trust in physicians was not associated with prolonged symptom duration (OR, 0.86; 95% CI, 0.66-1.11).

CONCLUSIONS

Perceived everyday discrimination was associated with prolonged symptom duration, whereas more commonly evaluated determinants of access to care and trust in physicians were not. These results suggest that more research on the effects of interpersonal barriers affecting ovarian cancer care is warranted.

Impact of Primary Care Delay on Progression of Breast Cancer in a Black African Population: A Multicentered Survey

BACKGROUND

Reports are scanty on the impact of long primary care interval in breast cancer. Exploratory reports in Nigeria and other low-middle-income countries suggest detrimental impact. The primary aim was to describe the impact of long primary care interval on breast cancer progression, and the secondary aim was to describe the factors perceived by patients as the reason(s) for long intervals.

METHOD

Questionnaire-based survey was used in 9 Nigerian tertiary institutions between May 2017 and July 2018. The study hypothesis was that the majority of patients stayed >30 days, and the majority experienced stage migration in primary care interval. Assessment of the impact of the length of interval on tumor stage was done by survival analysis technique, and clustering analysis was used to find subgroups of the patient journey.

RESULTS

A total of 237 patients presented to primary care personnel with tumor ≤5cm (mean 3.4±1.2cm). A total of 151 (69.3%, 95% CI 62.0-75.0) stayed >30 days in primary care interval. Risk of stage migration in primary care interval was 49.3% (95% CI 42.5%-56.3%). The most common reasons for long intervals were symptom misinformation and misdiagnosis. Clustering analysis showed 4 clusters of patients' experience and journey: long interval due to distance, long interval due to misinformation, long interval due to deliberate delaying, and not short interval-prepared for treatment.

CONCLUSION

The majority of patients stayed longer than 30 days in primary care interval. Long primary care interval was associated with a higher risk of stage migration, and more patients reported misinformation and misdiagnosis as reasons for a long interval.

Making sense of bodily sensations: Do shared cancer narratives influence symptom appraisal?

Though new or altered bodily sensations are a common occurrence they rarely transition to biomedically defined symptoms. When they do, sensations are subject to an appraisal process that can culminate in help-seeking. The transition has particular relevance for cancer diagnoses. Studies of 'symptom appraisal' in cancer patients typically conclude that failure to regard sensations as serious or 'symptom misattribution' results in lengthier help-seeking intervals. Though multiple influences on appraisal processes are acknowledged, including the socio-cultural context, detailed description and analyses of how socio-cultural factors shape appraisal is lacking. In this paper we explore one substantial component of the sociocultural context, namely, publicly recognised shared cancer narratives, and their impact on appraisal. We undertook a secondary analysis of 24 interviews with Scottish colorectal cancer patients originally completed in 2006-2007. Our analysis showed that fear, death and severity dominated cancer narratives and were frequently restated throughout interviews. Yet, early bodily changes were often mild and vague, were commonly experienced in the context of 'feeling well' and failed to match preconceived ideas of what cancer 'feels like'. Moreover, few perceived themselves to be 'at risk' of cancer and diagnoses were characterised as 'shocking' events. Participants engaged in self-monitoring strategies and severe or painful changes prompted help-seeking. Far from misattributing symptoms, responses to bodily changes were sensible and measured; responses are particularly apt in relation to current policy rhetoric, which urges measured use of services. Our findings have resonance across healthcare settings as patients are required to negotiate a narrow and challenging space when making decisions to seek help. There is a pressing need for a more realistic approach to symptom appraisal in order to reduce help-seeking intervals. Future awareness campaigns should emphasise the importance of vague/minor bodily changes although this will necessitate discussions with health professionals on referral thresholds to achieve earlier detection.

Cancer Control at the District Hospital Level in Sub-Saharan Africa: An Educational and Resource Needs Assessment of General Practitioners

PURPOSE

The WHO framework for early cancer diagnosis highlights the need to improve health care capacity among primary care providers. In Rwanda, general practitioners (GPs) at district hospitals (DHs) play key roles in diagnosing, initiating management, and referring suspected patients with cancer. We sought to ascertain educational and resource needs of GPs to provide a blueprint that can inform future early cancer diagnosis capacity–building efforts.

METHODS

We administered a cross-sectional survey study to GPs practicing in 42 Rwandan DHs to assess gaps in cancer-focused knowledge, skills, and resources, as well as delays in the referral process. Responses were aggregated and descriptive analysis was performed to identify trends.

RESULTS

Survey response rate was 76% (73 of 96 GPs). Most responders were 25 to 29 years of age (n = 64 [88%]) and 100% had been practicing between 3 and 12 months. Significant gaps in cancer knowledge and physical exam skills were identified—88% of respondents were comfortable performing breast exams, but less than 10 (15%) GPs reported confidence in performing pelvic exams. The main educational resource requested by responders (n = 59 [81%]) was algorithms to guide clinical decision-making. Gaps in resource availability were identified, with only 39% of responders reporting breast ultrasound availability and 5.8% reporting core needle biopsy availability in DHs. Radiology and pathology resources were limited, with 52 (71%) reporting no availability of pathology services at the DH level.

CONCLUSION

The current study reveals significant basic oncologic educational and resource gaps in Rwanda, such as physical examination skills and diagnostic tools. Capacity building for GPs in low- and middle-income countries should be a core component of national cancer control plans to improve accurate and timely diagnosis of cancer. Continuing professional development activities should address and focus on context-specific educational gaps, resource availability, and referral practice guidelines.

Mediating Factors in Early Diagnosis of Breast Cancer: from Initial Changes in Health to Breast Cancer Detection

Background:

Breast cancer is one of the most frequently occurring cancers in women throughout the world. In Iran, according to available reports, 70% of patients with breast cancer are detected at the advanced stages of the disease.

Materials and Methods:

This study is of descriptive-analytic cross-sectional type.160 female patients was selected. The data in this study was collected via face to face interview using a questionnaire based on the Anderson’s delay model. Data were analyzed using SPSS 22 and the significance level was considered to be 0.05.

Results:

The results showed that presence of mass was the first symptom in many of women, i.e., 76 cases (47.5%). not only the presence of mass in the breast, but also any other symptom, hadn’t been taken as a serious problem initially by women. Non-improvement of the symptoms and exacerbation of the symptoms was considered as a symptom of illness by patients. After considering the changes as the symptoms of illness, patients had tried to treat the disease through different methods of self-treatment. The failure of the self-treatment in controlling the symptoms, had directed the patients toward seeking for medical services. Out of 160 patients, 49 patients (39.6%) changed the time of their appointment with doctor. 110 cases (68%) out of 160 patients, rather than initiating relevant diagnostic procedure related to the disease, had received non-specific and non-related therapeutic measures.

Conclusion:

Pondering on the results yields that patient-related delays, resulting from their lack of awareness of the disease, cultural factors, and fear, can only play an important role in postponement of visiting a physician, but in the diagnosis of disease it is the inability of general practitioners in performing differential diagnoses, and making request for related diagnostic measures which can significantly increase the lag time until the onset of the main treatment.

Patient Factors Associated With Delays in Obtaining Cancer Care in Botswana

Purpose Delays in diagnosis and treatment of cancers can lead to poor survival. These delays represent a multifaceted problem attributable to patient, provider, and systemic factors. We aim to quantify intervals from symptom onset to treatment start among patients with cancer in Botswana and to understand potential risk factors for delay. Patients and Methods From December 2015 to January 2017, we surveyed patients seen in an oncology clinic in Botswana. We calculated proportions of patients who experienced delays in appraisal (between detecting symptoms and perceiving a reason to discuss them with provider, defined as > 1 month), help seeking (between discussing symptoms and first consultation with provider, defined as > 1 month), diagnosis (between first consultation and receiving a diagnosis, defined as > 3 months), and treatment (between diagnosis and starting treatment, defined as > 3 months). Results Among 214 patients with cancer who completed the survey, median age at diagnosis was 46 years, and the most common cancer was cancer of the cervix (42.2%). Eighty-one percent of patients were women, 60.7% were HIV infected, and 56.6% presented with advanced cancer (stage III or IV). Twenty-six percent of patients experienced delays in appraisal, 35.5% experienced delays help seeking, 63.1% experienced delays in diagnosis, and 50.4% experienced delays in treatment. Patient income, education, and age were not associated with delays. In univariable analysis, patients living with larger families were less likely to experience a help-seeking delay (odds ratio [OR], 0.31; P = .03), women and patients with perceived very serious symptoms were less likely to experience an appraisal delay (OR, 0.45; P = .032 and OR, 0.14; P = .02, respectively). Conclusion Nearly all patients surveyed experienced a delay in obtaining cancer care. In a setting where care is provided without charge, cancer type and male sex were more important predictors of delays than socioeconomic factors.

Impact of geographic distance on appraisal delay for active TB treatment seeking in Uganda: a network analysis of the Kawempe Community Health Cohort Study

Background

Appraisal delay is the time a patient takes to consider a symptom as not only noticeable, but a sign of illness. The study’s objective was to determine the association between appraisal delay in seeking tuberculosis (TB) treatment and geographic distance measured by network travel (driving and pedestrian) time (in minutes) and distance (Euclidean and self-reported) (in kilometers) and to identify other risk factors from selected covariates and how they modify the core association between delay and distance.

Methods

This was part of a longitudinal cohort study known as the Kawempe Community Health Study based in Kampala, Uganda. The study enrolled households from April 2002 to July 2012. Multivariable interval regression with multiplicative heteroscedasticity was used to assess the impact of time and distance on delay. The delay interval outcome was defined using a comprehensive set of 28 possible self-reported symptoms. The main independent variables were network travel time (in minutes) and Euclidean distance (in kilometers). Other covariates were organized according to the Andersen utilization conceptual framework.

Results

A total of 838 patients with both distance and delay data were included in the network analysis. Bivariate analyses did not reveal a significant association of any distance metric with the delay outcome. However, adjusting for patient characteristics and cavitary disease status, the multivariable model indicated that each minute of driving time to the clinic significantly (p = 0.02) and positively predicted 0.25 days’ delay. At the median distance value of 47 min, this represented an additional delay of about 12 (95% CI: [3, 21]) days to the mean of 40 days (95% CI: [25, 56]). Increasing Euclidean distance significantly predicted (p = 0.02) reduced variance in the delay outcome, thereby increasing precision of the mean delay estimate. At the median Euclidean distance of 2.8 km, the variance in the delay was reduced by more than 25%.

Conclusion

Of the four geographic distance measures, network travel driving time was a better and more robust predictor of mean delay in this setting. Including network travel driving time with other risk factors may be important in identifying populations especially vulnerable to delay.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5648-6) contains supplementary material, which is available to authorized users.

Patient awareness/knowledge towards oral cancer: a cross-sectional survey

Background

Oral cancer (OC) is associated with multiple risk factors and high mortality rates and substantially contributes to the global cancer burden despite being highly preventable.

This cross-sectional study sought to assess current knowledge, awareness, and behaviors of patients in rural communities surrounding OC risk.

Methods

An anonymous 21-question survey was distributed to patients in waiting rooms of a large integrated medical-dental health system serving north-central Wisconsin.

Survey results were summarized via descriptive statistics. Odds ratios surrounding health literacy on OC risk factors were obtained using unconditional univariate logistic regression analysis.

Results

Of 504 dental and 306 medical patients completing the survey, 62.2% were female, Caucasian/White (92%) with 41% having a ≤ high school diploma/equivalent. Current smoker/smokeless tobacco use was reported by 34%, while 39% reported former tobacco exposure. Alcohol use was reported by 54% of respondents at the following frequencies: < once/week, (35%); 1–2 times/week, (16%); 3–4 times/week, (6%); 5–6 times/week, (2%); and daily, (23%). Knowledge about tobacco and alcohol use and increased OC risk was reported by 94 and 40%, respectively. About 50% reported knowledgeability regarding cancer-associated symptomology. Tobacco cessation was reported by 20% of responders. Receipt of education on OC from healthcare providers and human papilloma virus links to OC causation was reported by 38 and 21%, respectively.

Conclusion

Patients who smoked > 20+ cigarettes per day were more knowledgeable about tobacco and OC risk compared to non-smokers and those who smoked ≤ 19 cigarettes/day (p = 0.0647). Patients who were alcohol consumers exhibited higher knowledgeability surrounding increased OC risk with alcohol and tobacco exposures compared to alcohol abstainers (p = 0.06). We concluded that patients recognized links between tobacco and OC risk but demonstrated lower knowledge of other causal factors. Strategic patient education by providers could increase awareness of OC risk.

Electronic supplementary material

The online version of this article (10.1186/s12903-018-0539-x) contains supplementary material, which is available to authorized users.

Breast self-exam and patient interval associate with advanced breast cancer and treatment delay in Mexican women

PURPOSE

The objective of this study was to compare treatment intervals in breast cancer patients according to the detection method (breast self-exam vs screening).

PATIENTS AND METHODS

We conducted a retrospective analysis including 291 breast cancer patients at a Mexican tertiary referral hospital.

RESULTS

Breast cancer detection method was mostly breast self-exam (60%). The median patient interval was 60.5 days, and was associated with marital status and socioeconomic level. Differences between the two groups were statistically significant for global interval, p = 0.002; however, health system interval was not statistically different.

CONCLUSION

In our country, breast cancer screening is opportunistic, with several weaknesses within its management and quality systems. Our study showed that even in specialized health care centers, breast cancer is detected by self-exam in up to 2/3 of patients, which can explain the advanced stages at diagnosis in our country. In developing countries, the immediate health care access for breast cancer patients should be prioritized as an initial step to reduce the global treatment initiation interval in order to reduce mortality.

Assessment of duration until initial treatment and its determining factors among newly diagnosed oral cancer patients: A population-based retrospective cohort study

Few studies have focused on the early treatment stages of cancer, and the impact of treatment delay on oncologic outcomes is poorly defined. We used oral cancer as an example to investigate the distribution of durations until initial treatment.This study was conducted using the National Health Insurance Research Database, which is linked to Taiwan's Cancer Registry and Death Registry databases. We defined "cutoff points for first-time treatment" according to a weekly schedule and sorted the patients into 2 groups based on whether their duration until initial treatment was longer or shorter than each cutoff. We then calculated the Kaplan-Meier estimator to determine the difference in survival rates between the 2 groups and performed logistic regression to identify determining factors.The average time between diagnosis and initial treatment was approximately 22.45 days. The average survival duration was 1363 days (standard deviation: 473.06 days). Oral cancer patients had no statistically significant differences in survival until a cutoff point of 3 weeks was used (with survival duration 71 days longer if initial treatment was received within 3 weeks). Patients with higher incomes or higher Charlson comorbidity index scores and patients treated at a hospital in a region with medium urbanization had lower likelihoods of treatment delay, whereas older patients were at higher risk of treatment delay.The attitudes, beliefs, and social contexts of oral cancer patients influence the treatment-seeking behaviors of these patients. Therefore, the government should advocate the merits of the referral system for cancer treatment or improve quality assurance for cancer diagnoses across different types of hospitals. Health authorities should also educate patients or use a case manager to encourage prompt treatment within 3 weeks and should provide screening and prevention services, particularly for high-risk groups, to reduce mortality risk.

Unintended consequences of an 'all-clear' diagnosis for potential cancer symptoms: a nested qualitative interview study with primary care patients

BACKGROUND

Nine out of 10 patients undergoing urgent cancer investigations receive an 'all-clear' diagnosis.

AIM

A qualitative approach was used to evaluate the impact of investigations that did not result in cancer diagnosis on subsequent symptom attribution and help seeking for recurrent or new possible cancer symptoms.

DESIGN AND SETTING

A survey of symptoms, help seeking, and past investigations was sent to 4913 individuals aged ≥50 years from four UK general practices. Of 2042 responders, 62 participants were recruited still reporting at least one cancer 'alarm' symptom in a 3-month follow-up survey for a nested in-depth interview study (ensuring variation in sociodemographic characteristics).

METHOD

Framework analysis was used to examine the in-depth semi-structured interviews and identify themes related to previous health investigations.

RESULTS

Interviewees were on average 65 years old, and 90% reported investigations within the previous 2 years. Most often they reported gastrointestinal, urinary, and respiratory symptoms, and 42% had waited ≥3 months before help seeking. Reassurance from a previous non-cancer diagnosis explained delays in help seeking even if symptoms persisted or new symptoms developed months or years later. Others were worried about appearing hypochondriacal or that they would not be taken seriously if they returned to the doctor.

CONCLUSION

An all-clear diagnosis can influence help seeking for months or even years in case of new or recurrent alarm symptoms. Considering the increasing number of people undergoing investigations and receiving an all-clear, it is paramount to limit unintended consequences by providing appropriate information and support. Specific issues are identified that could be addressed.

What prompts help-seeking for cancer 'alarm' symptoms? A primary care based survey

BACKGROUND

Encouraging prompt help-seeking for cancer symptoms can help shorten the patient interval and improve timely diagnosis. We explored factors associated with help-seeking in a primary care sample reporting 'alarm' symptoms.

METHODS

A questionnaire was mailed to 9771 adults (⩾ 50 years of age and no cancer diagnosis) and 3766 (39%) returned it. Our sample included 1732 adults reporting at least one cancer 'alarm' symptom; with a total of 2726 symptoms. Respondents completed questions relating to help-seeking, demographic and symptom characteristics (e.g., type, knowledge, concern, interference and attribution).

RESULTS

Over a third of people who reported a cancer 'alarm' symptom in the past 3 months had not sought help from a doctor. An unexplained lump (odds ratio (OR) 2.46, 1.42-4.26) and persistent unexplained pain (OR 1.79, 1.19-2.69) were associated with increased likelihood of help-seeking. Symptom concern (OR 3.10, 2.19-4.39) and interference (OR 3.06, 2.15-4.36) were associated with an increased likelihood of seeking help independently of symptom type. People who were not working (OR 1.41, 1.09-1.83), were married/cohabiting rather than single (OR 1.38, 1.10-1.74) and were older (60-69 years) rather than younger (50-59 years; OR 1.33, 1.02-1.75) were more likely to have sought help.

CONCLUSIONS

Our findings highlighted symptom type and symptom characteristics as key drivers of help-seeking. We also found that there may be specific demographic groups where encouraging help-seeking might be warranted.

Influences of cancer symptom knowledge, beliefs and barriers on cancer symptom presentation in relation to socioeconomic deprivation: a systematic review

BACKGROUND

People from lower socioeconomic groups have worse survival outcomes for cancer, which in part reflects later-stage disease at diagnosis. The mechanisms underlying delayed cancer symptom presentation in lower socioeconomic groups are not well understood.

METHODS

Systematic review of studies of actual or anticipated symptom presentation across all tumour sites. Included studies measured socioeconomic group, symptom presentation and one or more of the following variables: cancer symptom knowledge, beliefs about cancer, barriers/facilitators to symptom presentation.

RESULTS

A total of 60 studies was included. Symptom knowledge overall was lowest and actual presentation time was longest in lower socioeconomic groups. Knowledge for specific symptoms such as lumps and bleeding was good and encouraged timely symptom presentation, in contrast to non-specific symptoms which were not well recognised. The combination of fearful and fatalistic beliefs was typically associated with later presentation, especially in lower socioeconomic groups. Emotional barriers such as 'worry what the doctor might find' were more frequently reported in lower socioeconomic groups, and there was evidence to suggest that disclosing symptoms to family/friends could help or hinder early presentation.

CONCLUSIONS

Poor symptom knowledge, fearful and fatalistic beliefs about cancer, and emotional barriers combine to prolong symptom presentation among lower socioeconomic groups. Targeted interventions should utilise social networks to improve knowledge of non-specific symptoms, challenge negative beliefs and encourage help-seeking, in order to reduce avoidable delays and minimise socioeconomic group inequalities.

Does the Primary Care Experience Influence the Cancer Diagnostic Process?

Objective. To analyze the impact of patients' experience of care at their usual source of primary care on their choice of point of entry into cancer investigation process, time to diagnosis, and presence of metastatic cancer at time of diagnosis. Method. A questionnaire was administered to 438 patients with cancer (breast, lung, and colorectal) between 2011 and 2013 in four oncology clinics of Quebec (Canada). Multiple regression analyses (logistic and Cox models) were conducted. Results. Among patients with symptoms leading to investigation of cancer (n = 307), 47% used their usual source of primary care as the point of entry for investigation. Greater comprehensiveness of care was associated with the decision to use this source as point of entry (OR = 1.25; CI 90% = 1.06-1.46), as well as with shorter times between first symptoms and investigation (HR = 1.11; p = 0.05), while greater accessibility was associated with shorter times between investigation and diagnosis (HR = 1.13; p < 0.01).  Conclusion. Experience of care at the usual source of primary care has a slight influence on the choice of point of entry for cancer investigation and on time to diagnosis. This influence appears to be more related to patients' perceptions of the accessibility and comprehensiveness of their usual source of primary care.

Identifying the Factors Causing Delayed Presentation of Cancer Patients to a Government Medical College of Central India

BACKGROUND

The incidence of cancer is increasing throughout the world. One of the prime aims of its management is early diagnosis and therapeutic intervention. Factors causing delay to either of these goals should be identified and rectified.

AIM

To identify the factors causing delayed initial diagnosis and subsequent management in patients presenting to the Oncology department.

MATERIALS AND METHODS

Three hundred proven cancer patients were prospectively evaluated for the pattern of presentation to the outpatient Department of Radiation Oncology of a Government Medical College (MC) in Central India.

RESULTS

The mean age of presentation was 51.05 years (range 7 months-77 years). The number of male patients was 168 while females were 132. The duration of symptoms ranged from 20 days to 3 years. The number of patients with little/no education presented mainly in advanced stages as compared to their educated counterpart and this difference was statistically significant (p<0.001). The number of patients presenting directly to the department was 108, those diagnosed outside and referred to us was 84 while those diagnosed and received some form of oncologic treatment outside and referred thereafter was 108. The difference in the primary delay between patients presenting directly to the MC versus those diagnosed outside was significant (p=0.0126). The mean duration of starting definitive treatment after presentation to the outpatient was 4.68 days (range 0-22 days) and was very significantly (p< 0.001) less than the secondary delays caused to the other two subsets of patients.

CONCLUSION

Factors causing delayed presentation are both patient and system related. It is imperative to educate the common people regarding the early signs and symptoms of cancer. At the same time, the system needs to overhaul its efficiency to avoid secondary delays that adversely affect the treatment outcome. An upgradation of the existing oncology facilities in the public sector can achieve this target efficiently.