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Ha NT, Kamarova S, Youens D, Ho C, Bulsara MK, Doust J, Mcrobbie D, O'Leary P, Wright C, Trevithick R, Moorin R. Use of CT, ED presentation and hospitalisations 12 months before and after a diagnosis of cancer in Western Australia: a population-based retrospective cohort study. BMJ Open 2023; 13:e071052. [PMID: 37899144 PMCID: PMC10619095 DOI: 10.1136/bmjopen-2022-071052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 10/12/2023] [Indexed: 10/31/2023] Open
Abstract
OBJECTIVE To examine the use of CT, emergency department (ED)-presentation and hospitalisation and in 12 months before and after a diagnosis of cancer. DESIGN Population-based retrospective cohort study. SETTING West Australian linked administrative records at individual level. PARTICIPANTS 104 009 adults newly diagnosed with cancer in 2004-2014. MAIN OUTCOME MEASURES CT use, ED presentations, hospitalisations. RESULTS As compared with the rates in the 12th month before diagnosis, the rate of CT scans started to increase from 2 months before diagnosis with an increase in both ED presentations and hospitalisation from 1 month before the diagnosis. These rates peaked in the month of diagnosis for CT scans (477 (95% CI 471 to 482) per 1000 patients), and for hospitalisations (910 (95% CI 902 to 919) per 1000 patients), and the month prior to diagnosis for ED (181 (95% CI 178 to 184) per 1000 patients) then rapidly reduced after diagnosis but remained high for the next 12 months. While the patterns of the health services used were similar between 2004 and 2014, the rate of the health services used during after diagnosis was higher in 2014 versus 2004 except for CT use in patients with lymphohaematopoietic cancer with a significant reduction. CONCLUSION Our results showed an increase in demand for health services from 2 months before diagnosis of cancer. Increasing use of health services during and post cancer diagnosis may warrant further investigation to identify factors driving this change.
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Affiliation(s)
- Ninh Thi Ha
- School of Population Health, Curtin University, Perth, Western Australia, Australia
| | - Sviatlana Kamarova
- School of Population Health, Curtin University, Perth, Western Australia, Australia
- Sydney School of Health Sciences, University of Sydney, Sydney, New South Wales, Australia
- Nepean Blue Mountains Local Health District, New South Wales Health, Sydney, New South Wales, Australia
| | - David Youens
- School of Population Health, Curtin University, Perth, Western Australia, Australia
- Centre for Health Services Research, School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia
| | - Chau Ho
- School of Population Health, Curtin University, Perth, Western Australia, Australia
| | - Max K Bulsara
- Centre for Health Services Research, School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia
- Biostatistics, University of Notre Dame, Fremantle, Western Australia, Australia
| | - Jenny Doust
- Australian Women and Girls' Health Research (AWaGHR) Centre, Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Donald Mcrobbie
- School of Physical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Peter O'Leary
- School of Population Health, Curtin University, Perth, Western Australia, Australia
- Obstetrics and Gynaecology Medical School, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Western Australia, Australia
- PathWest Laboratory Medicine, QE2 Medical Centre, Nedlands, Western Australia, Australia
| | - Cameron Wright
- School of Population Health, Curtin University, Perth, Western Australia, Australia
- Fiona Stanley Hospital, Murdoch, Western Australia, Australia
- Division of Internal Medicine, Medical School, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Western Australia, Australia
- School of Medicine, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Richard Trevithick
- Western Australian Cancer Registry, Clinical Excellence Division, Department of Health, East Perth, Western Australia, Australia
| | - Rachael Moorin
- School of Population Health, Curtin University, Perth, Western Australia, Australia
- Centre for Health Services Research, School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia
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2
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Phelan A, Broughan J, McCombe G, Collins C, Fawsitt R, O’Callaghan M, Quinlan D, Stanley F, Cullen W. Impact of enhancing GP access to diagnostic imaging: A scoping review. PLoS One 2023; 18:e0281461. [PMID: 36897853 PMCID: PMC10004541 DOI: 10.1371/journal.pone.0281461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 01/24/2023] [Indexed: 03/11/2023] Open
Abstract
BACKGROUND Direct access to diagnostic imaging in General Practice provides an avenue to reduce referrals to hospital-based specialities and emergency departments, and to ensure timely diagnosis. Enhanced GP access to radiology imaging could potentially reduce hospital referrals, hospital admissions, enhance patient care, and improve disease outcomes. This scoping review aims to demonstrate the value of direct access to diagnostic imaging in General Practice and how it has impacted on healthcare delivery and patient care. METHODS A search was conducted of 'PubMed', 'Cochrane Library', 'Embase' and 'Google Scholar' for papers published between 2012-2022 using Arksey and O'Malley's scoping review framework. The search process was guided by the PRISMA extension for Scoping Reviews checklist (PRISMA-ScR). RESULTS Twenty-three papers were included. The studies spanned numerous geographical locations (most commonly UK, Denmark, and Netherlands), encompassing several study designs (most commonly cohort studies, randomised controlled trials and observational studies), and a range of populations and sample sizes. Key outcomes reported included the level of access to imaging serves, the feasibility and cost effectiveness of direct access interventions, GP and patient satisfaction with direct access initiatives, and intervention related scan waiting times and referral process. CONCLUSION Direct access to imaging for GPs can have many benefits for healthcare service delivery, patient care, and the wider healthcare ecosystem. GP focused direct access initiatives should therefore be considered as a desirable and viable health policy directive. Further research is needed to more closely examine the impacts that access to imaging studies have on health system operations, especially those in General Practice. Research examining the impacts of access to multiple imaging modalities is also warranted.
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Affiliation(s)
- Amy Phelan
- School of Medicine, University College Dublin, Dublin, Ireland
| | - John Broughan
- Clinical Research Centre, School of Medicine, University College Dublin, Dublin, Ireland
- * E-mail:
| | - Geoff McCombe
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Claire Collins
- Research, Policy and Information, Irish College of General Practitioners, Dublin, Ireland
| | - Ronan Fawsitt
- General Practice, Castle Gardens Medical Centre, Kilkenny, Ireland
- Primary Care Advisor, Ireland East Hospital Group, Dublin, Ireland
| | - Mike O’Callaghan
- Irish College of General Practitioners, ICGP, Dublin, Ireland
- School of Medicine, University of Limerick, Limerick, Ireland
| | | | - Fintan Stanley
- Irish College of General Practitioners, ICGP, Dublin, Ireland
| | - Walter Cullen
- School of Medicine, University College Dublin, Dublin, Ireland
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Zigman Suchsland M, Kowalski L, Burkhardt HA, Prado MG, Kessler LG, Yetisgen M, Au MA, Stephens KA, Farjah F, Schleyer AM, Walter FM, Neal RD, Lybarger K, Thompson CA, Achkar MA, Sarma EA, Turner G, Thompson M. How Timely Is Diagnosis of Lung Cancer? Cohort Study of Individuals with Lung Cancer Presenting in Ambulatory Care in the United States. Cancers (Basel) 2022; 14:5756. [PMID: 36497238 PMCID: PMC9740627 DOI: 10.3390/cancers14235756] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 10/22/2022] [Accepted: 11/16/2022] [Indexed: 11/25/2022] Open
Abstract
The diagnosis of lung cancer in ambulatory settings is often challenging due to non-specific clinical presentation, but there are currently no clinical quality measures (CQMs) in the United States used to identify areas for practice improvement in diagnosis. We describe the pre-diagnostic time intervals among a retrospective cohort of 711 patients identified with primary lung cancer from 2012-2019 from ambulatory care clinics in Seattle, Washington USA. Electronic health record data were extracted for two years prior to diagnosis, and Natural Language Processing (NLP) applied to identify symptoms/signs from free text clinical fields. Time points were defined for initial symptomatic presentation, chest imaging, specialist consultation, diagnostic confirmation, and treatment initiation. Median and interquartile ranges (IQR) were calculated for intervals spanning these time points. The mean age of the cohort was 67.3 years, 54.1% had Stage III or IV disease and the majority were diagnosed after clinical presentation (94.5%) rather than screening (5.5%). Median intervals from first recorded symptoms/signs to diagnosis was 570 days (IQR 273-691), from chest CT or chest X-ray imaging to diagnosis 43 days (IQR 11-240), specialist consultation to diagnosis 72 days (IQR 13-456), and from diagnosis to treatment initiation 7 days (IQR 0-36). Symptoms/signs associated with lung cancer can be identified over a year prior to diagnosis using NLP, highlighting the need for CQMs to improve timeliness of diagnosis.
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Affiliation(s)
| | - Lesleigh Kowalski
- Department of Family Medicine, University of Washington, Seattle, WA 98195, USA
| | - Hannah A. Burkhardt
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, WA 98195, USA
| | - Maria G. Prado
- Department of Family Medicine, University of Washington, Seattle, WA 98195, USA
| | - Larry G. Kessler
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA 98195, USA
| | - Meliha Yetisgen
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, WA 98195, USA
| | - Maggie A. Au
- Department of Family Medicine, University of Washington, Seattle, WA 98195, USA
| | - Kari A. Stephens
- Department of Family Medicine, University of Washington, Seattle, WA 98195, USA
| | - Farhood Farjah
- Department of Surgery, University of Washington, Seattle, WA 98195, USA
| | | | - Fiona M. Walter
- Wolfson Institute of Population Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London E1 4NS, UK
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge CB1 8RN, UK
| | - Richard D. Neal
- University of Exeter Medical School, University of Exeter, Exeter EX1 2LU, UK
| | - Kevin Lybarger
- Department of Information Sciences and Technology, George Mason University, Fairfax, VA 22039, USA
| | - Caroline A. Thompson
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Division of Epidemiology and Biostatistics, School of Public Health, San Diego State University, San Diego, CA 92182, USA
| | - Morhaf Al Achkar
- Department of Family Medicine, University of Washington, Seattle, WA 98195, USA
| | - Elizabeth A. Sarma
- Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD 20892, USA
| | - Grace Turner
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, WA 98195, USA
| | - Matthew Thompson
- Department of Family Medicine, University of Washington, Seattle, WA 98195, USA
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Saab MM, McCarthy M, O'Driscoll M, Sahm LJ, Leahy-Warren P, Noonan B, FitzGerald S, O'Malley M, Lyons N, Burns HE, Kennedy U, Lyng Á, Hegarty J. A systematic review of interventions to recognise, refer and diagnose patients with lung cancer symptoms. NPJ Prim Care Respir Med 2022; 32:42. [PMID: 36258020 PMCID: PMC9579201 DOI: 10.1038/s41533-022-00312-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 10/06/2022] [Indexed: 12/24/2022] Open
Abstract
Patients with lung cancer (LC) often experience delay between symptom onset and treatment. Primary healthcare professionals (HCPs) can help facilitate early diagnosis of LC through recognising early signs and symptoms and making appropriate referrals. This systematic review describes the effect of interventions aimed at helping HCPs recognise and refer individuals with symptoms suggestive of LC. Seven studies were synthesised narratively. Outcomes were categorised into: Diagnostic intervals; referral and diagnosis patterns; stage distribution at diagnosis; and time interval from diagnosis to treatment. Rapid access pathways and continuing medical education for general practitioners can help reduce LC diagnostic and treatment delay. Awareness campaigns and HCP education can help inform primary HCPs about referral pathways. However, campaigns did not significantly impact LC referral rates or reduce diagnostic intervals. Disease outcomes, such as LC stage at diagnosis, recurrence, and survival were seldom measured. Review findings highlight the need for longitudinal, powered, and controlled studies.
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Affiliation(s)
- Mohamad M Saab
- Catherine McCauley School of Nursing and Midwifery, University College Cork, Cork, Ireland.
| | - Megan McCarthy
- Catherine McCauley School of Nursing and Midwifery, University College Cork, Cork, Ireland
| | - Michelle O'Driscoll
- Catherine McCauley School of Nursing and Midwifery, University College Cork, Cork, Ireland
| | - Laura J Sahm
- School of Pharmacy, University College Cork, Cork, Ireland
| | - Patricia Leahy-Warren
- Catherine McCauley School of Nursing and Midwifery, University College Cork, Cork, Ireland
| | - Brendan Noonan
- Catherine McCauley School of Nursing and Midwifery, University College Cork, Cork, Ireland
| | - Serena FitzGerald
- Catherine McCauley School of Nursing and Midwifery, University College Cork, Cork, Ireland
| | - Maria O'Malley
- Catherine McCauley School of Nursing and Midwifery, University College Cork, Cork, Ireland
| | - Noreen Lyons
- Rapid Access Lung Clinic, Cork University Hospital, Cork, Ireland
| | - Heather E Burns
- National Cancer Control Programme, Health Services Executive, Dublin, Ireland
| | - Una Kennedy
- National Cancer Control Programme, Health Services Executive, Dublin, Ireland
| | - Áine Lyng
- National Cancer Control Programme, Health Services Executive, Dublin, Ireland
| | - Josephine Hegarty
- Catherine McCauley School of Nursing and Midwifery, University College Cork, Cork, Ireland
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5
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Bonney A, Malouf R, Marchal C, Manners D, Fong KM, Marshall HM, Irving LB, Manser R. Impact of low-dose computed tomography (LDCT) screening on lung cancer-related mortality. Cochrane Database Syst Rev 2022; 8:CD013829. [PMID: 35921047 PMCID: PMC9347663 DOI: 10.1002/14651858.cd013829.pub2] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Lung cancer is the most common cause of cancer-related death in the world, however lung cancer screening has not been implemented in most countries at a population level. A previous Cochrane Review found limited evidence for the effectiveness of lung cancer screening with chest radiography (CXR) or sputum cytology in reducing lung cancer-related mortality, however there has been increasing evidence supporting screening with low-dose computed tomography (LDCT). OBJECTIVES: To determine whether screening for lung cancer using LDCT of the chest reduces lung cancer-related mortality and to evaluate the possible harms of LDCT screening. SEARCH METHODS We performed the search in collaboration with the Information Specialist of the Cochrane Lung Cancer Group and included the Cochrane Lung Cancer Group Trial Register, Cochrane Central Register of Controlled Trials (CENTRAL, the Cochrane Library, current issue), MEDLINE (accessed via PubMed) and Embase in our search. We also searched the clinical trial registries to identify unpublished and ongoing trials. We did not impose any restriction on language of publication. The search was performed up to 31 July 2021. SELECTION CRITERIA: Randomised controlled trials (RCTs) of lung cancer screening using LDCT and reporting mortality or harm outcomes. DATA COLLECTION AND ANALYSIS: Two review authors were involved in independently assessing trials for eligibility, extraction of trial data and characteristics, and assessing risk of bias of the included trials using the Cochrane RoB 1 tool. We assessed the certainty of evidence using GRADE. Primary outcomes were lung cancer-related mortality and harms of screening. We performed a meta-analysis, where appropriate, for all outcomes using a random-effects model. We only included trials in the analysis of mortality outcomes if they had at least 5 years of follow-up. We reported risk ratios (RRs) and hazard ratios (HRs), with 95% confidence intervals (CIs) and used the I2 statistic to investigate heterogeneity. MAIN RESULTS: We included 11 trials in this review with a total of 94,445 participants. Trials were conducted in Europe and the USA in people aged 40 years or older, with most trials having an entry requirement of ≥ 20 pack-year smoking history (e.g. 1 pack of cigarettes/day for 20 years or 2 packs/day for 10 years etc.). One trial included male participants only. Eight trials were phase three RCTs, with two feasibility RCTs and one pilot RCT. Seven of the included trials had no screening as a comparison, and four trials had CXR screening as a comparator. Screening frequency included annual, biennial and incrementing intervals. The duration of screening ranged from 1 year to 10 years. Mortality follow-up was from 5 years to approximately 12 years. None of the included trials were at low risk of bias across all domains. The certainty of evidence was moderate to low across different outcomes, as assessed by GRADE. In the meta-analysis of trials assessing lung cancer-related mortality, we included eight trials (91,122 participants), and there was a reduction in mortality of 21% with LDCT screening compared to control groups of no screening or CXR screening (RR 0.79, 95% CI 0.72 to 0.87; 8 trials, 91,122 participants; moderate-certainty evidence). There were probably no differences in subgroups for analyses by control type, sex, geographical region, and nodule management algorithm. Females appeared to have a larger lung cancer-related mortality benefit compared to males with LDCT screening. There was also a reduction in all-cause mortality (including lung cancer-related) of 5% (RR 0.95, 95% CI 0.91 to 0.99; 8 trials, 91,107 participants; moderate-certainty evidence). Invasive tests occurred more frequently in the LDCT group (RR 2.60, 95% CI 2.41 to 2.80; 3 trials, 60,003 participants; moderate-certainty evidence). However, analysis of 60-day postoperative mortality was not significant between groups (RR 0.68, 95% CI 0.24 to 1.94; 2 trials, 409 participants; moderate-certainty evidence). False-positive results and recall rates were higher with LDCT screening compared to screening with CXR, however there was low-certainty evidence in the meta-analyses due to heterogeneity and risk of bias concerns. Estimated overdiagnosis with LDCT screening was 18%, however the 95% CI was 0 to 36% (risk difference (RD) 0.18, 95% CI -0.00 to 0.36; 5 trials, 28,656 participants; low-certainty evidence). Four trials compared different aspects of health-related quality of life (HRQoL) using various measures. Anxiety was pooled from three trials, with participants in LDCT screening reporting lower anxiety scores than in the control group (standardised mean difference (SMD) -0.43, 95% CI -0.59 to -0.27; 3 trials, 8153 participants; low-certainty evidence). There were insufficient data to comment on the impact of LDCT screening on smoking behaviour. AUTHORS' CONCLUSIONS: The current evidence supports a reduction in lung cancer-related mortality with the use of LDCT for lung cancer screening in high-risk populations (those over the age of 40 with a significant smoking exposure). However, there are limited data on harms and further trials are required to determine participant selection and optimal frequency and duration of screening, with potential for significant overdiagnosis of lung cancer. Trials are ongoing for lung cancer screening in non-smokers.
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Affiliation(s)
- Asha Bonney
- Department of Respiratory and Sleep Medicine, Royal Melbourne Hospital, Parkville, Australia
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Reem Malouf
- National Perinatal Epidemiology Unit (NPEU), University of Oxford, Oxford, UK
| | | | - David Manners
- Respiratory Medicine, Midland St John of God Public and Private Hospital, Midland, Australia
| | - Kwun M Fong
- Thoracic Medicine Program, The Prince Charles Hospital, Brisbane, Australia
- UQ Thoracic Research Centre, School of Medicine, The University of Queensland, Brisbane, Australia
| | - Henry M Marshall
- School of Medicine, The University of Queensland, Brisbane, Australia
| | - Louis B Irving
- Department of Respiratory and Sleep Medicine, Royal Melbourne Hospital, Parkville, Australia
| | - Renée Manser
- Department of Respiratory and Sleep Medicine, Royal Melbourne Hospital, Parkville, Australia
- Department of Haematology and Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
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6
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Sajid IM, Frost K, Paul AK. 'Diagnostic downshift': clinical and system consequences of extrapolating secondary care testing tactics to primary care. BMJ Evid Based Med 2022; 27:141-148. [PMID: 34099498 DOI: 10.1136/bmjebm-2020-111629] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/09/2021] [Indexed: 12/21/2022]
Abstract
Numerous drivers push specialist diagnostic approaches down to primary care ('diagnostic downshift'), intuitively welcomed by clinicians and patients. However, primary care's different population and processes result in under-recognised, unintended consequences. Testing performs poorer in primary care, with indication creep due to earlier, more undifferentiated presentation and reduced accuracy due to spectrum bias and the 'false-positive paradox'. In low-prevalence settings, tests without near-100% specificity have their useful yield eclipsed by greater incidental or false-positive findings. Ensuing cascades and multiplier effects can generate clinician workload, patient anxiety, further low-value tests, referrals, treatments and a potentially nocebic population 'disease' burden of unclear benefit. Increased diagnostics earlier in pathways can burden patients and stretch general practice (GP) workloads, inducing downstream service utilisation and unintended 'market failure' effects. Evidence is tenuous for reducing secondary care referrals, providing patient reassurance or meaningfully improving clinical outcomes. Subsequently, inflated investment in per capita testing, at a lower level in a healthcare system, may deliver diminishing or even negative economic returns. Test cost poorly represents 'value', neglecting under-recognised downstream consequences, which must be balanced against therapeutic yield. With lower positive predictive values, more tests are required per true diagnosis and cost-effectiveness is rarely robust. With fixed secondary care capacity, novel primary care testing is an added cost pressure, rarely reducing hospital activity. GP testing strategies require real-world evaluation, in primary care populations, of all downstream consequences. Test formularies should be scrutinised in view of the setting of care, with interventions to focus rational testing towards those with higher pretest probabilities, while improving interpretation and communication of results.
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Affiliation(s)
- Imran Mohammed Sajid
- NHS West London Clinical Commissioning Group, London, UK
- University of Global Health Equity, Kigali, Rwanda
| | - Kathleen Frost
- NHS Central London Clinical Commissioning Group, London, UK
| | - Ash K Paul
- NHS South West London Health and Care Partnership STP, London, UK
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7
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Hyldgaard C, Trolle C, Harders SMW, Engberg H, Rasmussen TR, Møller H. Increased use of diagnostic CT imaging increases the detection of stage IA lung cancer: pathways and patient characteristics. BMC Cancer 2022; 22:464. [PMID: 35477356 PMCID: PMC9047294 DOI: 10.1186/s12885-022-09585-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 04/04/2022] [Indexed: 11/15/2022] Open
Abstract
Background At Silkeborg Regional Hospital, Denmark, the number of stage IA lung cancer increased after implementation of increased use of CT investigations and a corresponding reduction in chest X-ray. The aim of the present study was to understand the changes in referral pathways, patient characteristics and imaging procedures behind the observed increase in early-stage lung cancer. Methods The referral and imaging pathways for all patients diagnosed with lung cancer in 2013–2018 were described based on manually curated information from the electronic health care systems and staging information from the Danish Lung Cancer Registry. We compared the clinical characteristics of patients diagnosed in 2013–2015 and in 2016–2018 after implementation of a change in the use of low dose CT scan (LDCT). For patients diagnosed in 2016–2018, stage IA lung cancer were compared to higher stages using univariable logistic regression analysis. Results Five hundred and forty-seven patients were diagnosed with lung cancer in 2013–2018. Stage IA constituted 13.8% (34/247) in 2013–2015, and 28.3% (85/300) in 2016–2018. Stage IA patients in 2016–2018 were characterised by more comorbidity, fewer packyears and tended to be older than patients with higher stages. In 2016–2018, the largest proportion of stage IA patients (55%) came from within-hospital referrals. The majority of these lung cancers were detected due to imaging procedures with other indications than suspicion of lung cancer. The proportion of stage IA increased from 12% (12/99) to 36% (47/129) (p < 0.001) for hospital referrals and from 17% (22/129) to 23% (38/165) for GP referrals (p = 0.21). The imaging procedures contributing to the increase in stage IA was contrast enhanced CT (22%¸11/51), LDCT (35%; 18/51) and X-ray followed by LDCT (25%; 13/51). Conclusion The increased access to LDCT for patients referred from general practice and the increased hospital requested CT activity resulted in an increase in the number of stage IA lung cancers. Incidental findings on imaging performed for diagnostic purposes unrelated to suspicion of lung cancer contributed a large proportion of the increase. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-022-09585-2.
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Affiliation(s)
- Charlotte Hyldgaard
- Diagnostic Centre, Silkeborg Regional Hospital, Falkevej 1-3, Silkeborg, Denmark.
| | - Christian Trolle
- Diagnostic Centre, Silkeborg Regional Hospital, Falkevej 1-3, Silkeborg, Denmark
| | - Stefan Markus Walbom Harders
- Diagnostic Centre, Silkeborg Regional Hospital, Falkevej 1-3, Silkeborg, Denmark.,Department of Radiology, Odense University Hospital, Odense, Denmark
| | - Henriette Engberg
- The Danish Clinical Quality Program and Clinical Registries (RKKP), Aarhus, Denmark
| | - Torben Riis Rasmussen
- Department of Respiratory Disease and Allergy, Aarhus University Hospital, Aarhus, Denmark
| | - Henrik Møller
- The Danish Clinical Quality Program and Clinical Registries (RKKP), Aarhus, Denmark.,Danish Centre for Clinical Health Services Research, Aalborg University, Aalborg, Denmark
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8
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Zhang J, Oberoi J, Karnchanachari N, IJzerman MJ, Bergin RJ, Druce P, Franchini F, Emery JD. A systematic overview on risk factors and effective interventions to reduce time to diagnosis and treatment in lung cancer. Lung Cancer 2022; 166:27-39. [DOI: 10.1016/j.lungcan.2022.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 01/12/2022] [Accepted: 01/20/2022] [Indexed: 11/25/2022]
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9
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Kalajdzic O, Pavlović J. ASSESSMENT OF QUALITY OF LIFE PATIENTS SUFFERING FROM BREAST CANCER AND LUNG CANCER. SANAMED 2021. [DOI: 10.24125/sanamed.v16i1.480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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10
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White V, Bergin RJ, Thomas RJ, Whitfield K, Weller D. The pathway to diagnosis and treatment for surgically managed lung cancer patients. Fam Pract 2020; 37:234-241. [PMID: 31665265 DOI: 10.1093/fampra/cmz064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Most lung cancer is diagnosed at an advanced stage, resulting in poor survival. This study examined diagnostic pathways for patients with operable lung cancer to identify factors contributing to early diagnosis. METHODS Surgically treated lung cancer patients (aged ≥40, within 6 months of diagnosis), approached via the population-based Cancer Registry, with their primary care physicians (PCPs) and specialists completed cross-sectional surveys assessing symptoms, diagnostic route (symptomatic or 'investigation' of other problem), tests, key event dates and treatment. Time intervals to diagnosis and treatment were determined, and quantile regression examined differences between the two diagnostic routes. Cox proportional hazard regression analyses examined associations between survival and diagnostic route adjusting for stage, sex and age. RESULTS One hundred and ninety-two patients (36% response rate), 107 PCPs and 55 specialists participated. Fifty-eight per cent of patients had a symptomatic diagnostic route reporting an average of 1.6 symptoms, most commonly cough, fatigue or haemoptysis. Symptomatic patients had longer median primary care interval than 'investigation' patients (12 versus 9 days, P < 0.05) and were more likely to report their PCP first-ordered imaging tests. Secondary care interval was shorter for symptomatic (median = 43 days) than investigation (median = 62 days, P < 0.05) patients. However, 56% of all patients waited longer than national recommendations (6 weeks). While survival estimates were better for investigation than symptomatic patients, these differences were not significant. CONCLUSION Many operable lung cancer patients are diagnosed incidentally, highlighting the difficulty of symptom-based approaches to diagnosing early stage disease. Longer than recommended secondary care interval suggests the need for improvements in care pathways.
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Affiliation(s)
- Victoria White
- School of Psychology, Deakin University, Burwood, Australia.,Centre for Behavioural Research in Cancer, Melbourne, Australia
| | - Rebecca J Bergin
- Cancer Epidemiology Division, Cancer Council Victoria, Melbourne, Australia.,Department of General Practice and Centre for Cancer Research, University of Melbourne, Victorian Comprehensive Cancer Centre, Melbourne, Australia
| | - Robert J Thomas
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia.,Department of Health and Human Services Victoria, Victorian Government, Melbourne, Australia
| | - Kathryn Whitfield
- Department of Health and Human Services Victoria, Victorian Government, Melbourne, Australia
| | - David Weller
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, United Kingdom
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Winthereik AK, Neergaard MA, Jensen AB, Vedsted P. Development, modelling, and pilot testing of a complex intervention to support end-of-life care provided by Danish general practitioners. BMC FAMILY PRACTICE 2018; 19:91. [PMID: 29925332 PMCID: PMC6011239 DOI: 10.1186/s12875-018-0774-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 05/25/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Most patients in end-of-life with life-threatening diseases prefer to be cared for and die at home. Nevertheless, the majority die in hospitals. GPs have a pivotal role in providing end-of-life care at patients' home, and their involvement in the palliative trajectory enhances the patient's possibility to stay at home. The aim of this study was to develop and pilot-test an intervention consisting of continuing medical education (CME) and electronic decision support (EDS) to support end-of-life care in general practice. METHODS We developed an intervention in line with the first phases of the guidelines for complex interventions drawn up by the Medical Research Council. Phase 1 involved the development of the intervention including identification of key barriers to provision of end-of-life care for GPs and of facilitators of change. Furthermore the actual modelling of two components: CME meeting and EDS. Phase 2 focused on pilot-testing and intervention assessment by process evaluation. RESULTS In phase 1 lack of identification of patients at the end of life and limited palliative knowledge among GPs were identified as barriers. The CME meeting and the EDS were developed. The CME meeting was a four-hour educational meeting performed by GPs and specialists in palliative care. The EDS consisted of two parts: a pop-up window for each patient with palliative needs and a list of all patients with palliative needs in the practice. The pilot testing in phase 2 showed that the CME meeting was performed as intended and 120 (14%) of the GPs in the region attended. The EDS was integrated in existing electronic records but was shut down early for external reasons; 50 (5%) GPs signed up. The pilot-testing demonstrated a need to strengthen the implementation as attending rate was low in the current set-up. CONCLUSION We developed a complex intervention to support GPs in providing end-of-life care. The pilot-test showed general acceptance of the CME meetings. The EDS was shut down early and needs further evaluation before examining the whole intervention in a larger study, where evaluation could be based on patient-related outcomes and impact on end-of-life care. TRIAL REGISTRATION Clinicaltrials.gov ( NCT02050256 ) January 30, 2014.
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Affiliation(s)
- Anna Kirstine Winthereik
- Department of Oncology, Aarhus University Hospital, Noerrebrogade 44, 8000, Aarhus C, Denmark.
- Department of Clinical Medicine, Aarhus University, Noerrebrogade 44, 8000, Aarhus C, Denmark.
| | - Mette Asbjoern Neergaard
- Palliative Care Team, Department of Oncology, Aarhus University Hospital, Noerrebrogade 44, 8000, Aarhus, Denmark
| | - Anders Bonde Jensen
- Department of Oncology, Aarhus University Hospital, Noerrebrogade 44, 8000, Aarhus C, Denmark
| | - Peter Vedsted
- Research Unit for General Practice, Department of Public Health, Aarhus University, Bartholins Allé 2, 8000, Aarhus, Denmark
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Abstract
Lung cancer has been transformed from a rare disease into a global problem and public health issue. The etiologic factors of lung cancer become more complex along with industrialization, urbanization, and environmental pollution around the world. Currently, the control of lung cancer has attracted worldwide attention. Studies on the epidemiologic characteristics of lung cancer and its relative risk factors have played an important role in the tertiary prevention of lung cancer and in exploring new ways of diagnosis and treatment. This article reviews the current evolution of the epidemiology of lung cancer.
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Affiliation(s)
- Yousheng Mao
- Department of Thoracic Surgery, Cancer Institute and Hospital, Chinese Academy of Medical Sciences, Beijing 100021, China
| | - Ding Yang
- Department of Thoracic Surgery, Cancer Institute and Hospital, Chinese Academy of Medical Sciences, Beijing 100021, China
| | - Jie He
- Department of Thoracic Surgery, Cancer Institute and Hospital, Chinese Academy of Medical Sciences, Beijing 100021, China.
| | - Mark J Krasna
- Meridian Cancer Care, Jersey Shore University Medical Center, Ackerman South-Room 553, 1945 Route 33, Neptune City, NJ 07753, USA.
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13
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Timeliness of access to lung cancer diagnosis and treatment: A scoping literature review. Lung Cancer 2017; 112:156-164. [DOI: 10.1016/j.lungcan.2017.08.011] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 08/02/2017] [Accepted: 08/09/2017] [Indexed: 11/18/2022]
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14
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Neal RD, Barham A, Bongard E, Edwards RT, Fitzgibbon J, Griffiths G, Hamilton W, Hood K, Nelson A, Parker D, Porter C, Prout H, Roberts K, Rogers T, Thomas-Jones E, Tod A, Yeo ST, Hurt CN. Immediate chest X-ray for patients at risk of lung cancer presenting in primary care: randomised controlled feasibility trial. Br J Cancer 2017; 116:293-302. [PMID: 28072761 PMCID: PMC5294478 DOI: 10.1038/bjc.2016.414] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 10/31/2016] [Accepted: 11/16/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Achieving earlier stage diagnosis is one option for improving lung cancer outcomes in the United Kingdom. Patients with lung cancer typically present with symptoms to general practitioners several times before referral or investigation. METHODS We undertook a mixed methods feasibility individually randomised controlled trial (the ELCID trial) to assess the feasibility and inform the design of a definitive, fully powered, UK-wide, Phase III trial of lowering the threshold for urgent investigation of suspected lung cancer. Patients over 60, with a smoking history, presenting with new chest symptoms to primary care, were eligible to be randomised to intervention (urgent chest X-ray) or usual care. RESULTS The trial design and materials were acceptable to GPs and patients. We randomised 255 patients from 22 practices, although the proportion of eligible patients who participated was lower than expected. Survey responses (89%), and the fidelity of the intervention (82% patients X-rayed within 3 weeks) were good. There was slightly higher anxiety and depression in the control arm in participants aged >75. Three patients (1.2%) were diagnosed with lung cancer. CONCLUSIONS We have demonstrated the feasibility of individually randomising patients at higher risk of lung cancer, to a trial offering urgent investigation or usual care.
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Affiliation(s)
- Richard D Neal
- Leeds Institute for Health Sciences, University of Leeds, Leeds LS2 9NL, UK
| | | | - Emily Bongard
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | | | | | - Gareth Griffiths
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | | | - Kerenza Hood
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Annmarie Nelson
- Marie Curie Palliative Care Research Centre School of Medicine, Cardiff University, Cardiff, UK
| | - David Parker
- Betsi Cadwaladr University Health Board, Wrexham Maelor Hospital, Wrexham, UK
| | - Cath Porter
- Wales Cancer Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Hayley Prout
- Marie Curie Palliative Care Research Centre School of Medicine, Cardiff University, Cardiff, UK
| | - Kirsty Roberts
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Trevor Rogers
- Doncaster Royal Infirmary, Doncaster and Bassetlaw NHS Foundation Trust, Doncaster, UK
| | - Emma Thomas-Jones
- South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, UK
| | | | - Seow Tien Yeo
- Centre for Health Economics and Medicines Evaluation, Bangor University, Gwynedd, UK
| | - Chris N Hurt
- Wales Cancer Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, UK
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15
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Abstract
Much time, effort and investment goes into the diagnosis of symptomatic cancer, with the expectation that this approach brings clinical benefits. This investment of resources has been particularly noticeable in the UK, which has, for several years, appeared near the bottom of international league tables for cancer survival in economically developed countries. In this Review, we examine expedited diagnosis of cancer from four perspectives. The first relates to the potential for clinical benefits of expedited diagnosis of symptomatic cancer. Limited evidence from clinical trials is available, but the considerable observational evidence suggests benefits can be obtained from this approach. The second perspective considers how expedited diagnosis can be achieved. We concentrate on data from the UK, where extensive awareness campaigns have been conducted, and initiatives in the primary-care setting, including clinical decision support, have all occurred during a period of considerable national policy change. The third section considers the most appropriate patients for cancer investigations, and the possible community settings for identification of such patients; UK national guidance for selection of patients for investigation is discussed. Finally, the health economics of expedited diagnosis are reviewed, although few studies provide definitive evidence on this topic.
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Affiliation(s)
- Willie Hamilton
- University of Exeter, College House, St Luke's Campus, Exeter EX2 4TE, UK
| | - Fiona M Walter
- Department of Public Health &Primary Care, University of Cambridge, Cambridge CB1 8RN, UK
| | - Greg Rubin
- School of Medicine, Pharmacy and Health, Wolfson Building, Queen's Campus, University of Durham, Stockton-on-Tees TS17 6BH, UK
| | - Richard D Neal
- North Wales Centre for Primary Care Research, Bangor University, Gwenfro Unit 5, Wrexham Technology Park, Wrexham LL13 7YP, UK
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Barisic A, Kish M, Gilbert J, Mittmann N, Moineddin R, Sisler J, Vedsted P, Grunfeld E. Family physician access to and wait times for cancer diagnostic investigations: Regional differences among 3 provinces. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2016; 62:e599-e607. [PMID: 27737995 PMCID: PMC5063786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To examine provincial and regional differences in FPs' direct access to cancer diagnostic investigations and advice from other specialists regarding investigations and referrals, and to explore FPs' perceptions about wait times for diagnostic investigations and receipt of results. DESIGN A cross-sectional, online survey. SETTING British Columbia, Manitoba, and Ontario. PARTICIPANTS A sample of FPs from participating provinces. MAIN OUTCOME MEASURES Direct FP access to various diagnostic investigations and advice from other specialists regarding investigations and referrals; FPs' perceptions about wait times for diagnostic investigations ordered directly; and FPs' perceptions about wait times for results. RESULTS A total of 1054 surveys were completed by FPs from British Columbia (n = 229), Manitoba (n = 228), and Ontario (n = 597). Distance from a cancer centre was not significantly associated with direct access to or wait times for diagnostic investigations for most of the investigations studied; however, provincial differences were observed. Family physicians in Manitoba and British Columbia were 30% to 45% less likely to report having direct access to endoscopy and some imaging investigations compared with FPs in Ontario. Family physicians in Manitoba and British Columbia were also at increased odds of waiting longer than 12 weeks for endoscopy investigations and longer than 4 weeks for imaging investigations compared with FPs in Ontario. Most FPs reported wait times of less than 2 weeks for imaging results; however, the proportion of FPs who waited longer than 2 weeks for colonoscopy results ranged from 15% in Ontario to 96% in British Columbia. CONCLUSION Given the disparities observed among provinces, there is an opportunity for provinces to learn from one another to improve direct access to and shorten wait times for diagnostic investigations. This in turn has the potential to shorten the primary care interval for cancer diagnostic assessment.
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Affiliation(s)
- Andriana Barisic
- Senior Research Associate for the Ontario Renal Network of Cancer Care Ontario in Toronto, Ont, and was with the Department of Prevention and Cancer Control at the time of manuscript development.
| | - Maxine Kish
- Research Associate at Cancer Care Ontario and was a master's student in the Department of Pharmacology and Toxicology at the University of Toronto
| | - Julie Gilbert
- Staff scientist and Manager of Research and Evaluation at Cancer Care Ontario and Adjunct Professor in the Institute for Health Policy, Management and Evaluation at the University of Toronto
| | | | - Rahim Moineddin
- Professor and a senior biostatistician in the Department of Family and Community Medicine at the University of Toronto
| | - Jeffrey Sisler
- Chair of the College of Family Physicians of Canada's Cancer Care Program of the Section of Communities of Practice in Family Medicine and Vice-Dean of the Office of Continuing Competency and Assessment in the Faculty of Health Sciences and Professor in the Department of Family Medicine at the University of Manitoba in Winnipeg
| | - Peter Vedsted
- Professor in the Research Unit for General Practice in the Department of Public Health at Aarhus University in Denmark
| | - Eva Grunfeld
- Giblon Professor and Vice-Chair of Research in the Department of Family and Community Medicine at the University of Toronto and Director of Knowledge Translation Research in the Health Services Research Program at the Ontario Institute for Cancer Research
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