Time to diagnosis and associated costs of an outpatient vs inpatient setting in the diagnosis of lymphoma: a retrospective study of a large cohort of major lymphoma subtypes in Spain

Pathways to cancer care after a suspected cancer diagnosis in the emergency department: a survey of emergency physicians across Ontario

INTRODUCTION

Little is known about how patients are managed after a suspected cancer diagnosis through the emergency department. The objective of this study was to examine the ED management, specifically referral practices, for ten suspected cancer diagnoses by emergency physicians across Ontario and to explore variability in management by cancer-type and centre.

METHODS

An electronic survey was distributed to emergency physicians across Ontario, asking about referral practices for patients who could be discharged from the ED with one of ten suspected cancer diagnoses. Options for referral included: in-ED consult, outpatient medical or surgical specialists, surgical or medical oncology, and specialized cancer clinics. Data were described using frequencies and proportions. Variance partition coefficients were calculated to determine variation in responses attributed to differences between hospitals, with physicians nested within hospitals.

RESULTS

262 physicians from 54 EDs responded. Across most cancers, emergency physicians would refer to surgical specialists for further work-up; however, this ranged from 30.2% for lung cancer to 69.5% for head and neck cancer. For patients with an unknown primary malignancy, most physicians would refer to internal medicine clinic (34.3%) or obtain an in-ED consult (25.0%). Few physicians would refer directly to surgical or medical oncology from the ED. Comments suggest this may be due to oncologists requiring tissue confirmation of malignancy. Most referrals to specialized clinics were for suspected lung (30.2%) or breast cancer (19.5%); however, these appear to only be available at some centres. Variance in referrals between hospitals was lowest for breast cancer (variance partition coefficient = 8.6%) and highest for unknown primary malignancies (variance partition coefficient = 29.8%).

INTERPRETATION

Physician management of new suspected cancer varies between EDs and is specific to cancer type. Strategies to standardize access to cancer care in a timely and equitable way for patients with newly suspected cancer in the ED are needed.

Emergency department use before cancer diagnosis in Ontario, Canada: a population-based study

BACKGROUND

Although suspicions of cancer may be raised in patients who visit the emergency department, little is known about emergency department use before a cancer diagnosis. We sought to describe emergency department use among patients in Ontario within the 90 days before confirmed cancer diagnosis and to evaluate factors associated with this emergency department use.

METHODS

We conducted a retrospective, population-based study of patients aged 18 years or older who had a confirmed cancer diagnosis in Ontario from 2014 to 2021 using linked administrative databases. The primary outcome was any emergency department visit within 90 days before the cancer diagnosis date. We used multivariable logistic regression to evaluate factors associated with emergency department use, such as demographics (e.g., age, sex, rurality, Ontario Health region, indicators of marginalization), comorbidities, previous emergency department visits and hospital admissions, continuity of primary care, type of cancer, and year of cancer diagnosis.

RESULTS

We included 651 071 patients with cancer. Of these, 229 683 (35.3%) had an emergency department visit within 90 days before diagnosis, 51.4% of whom were admitted to hospital from the emergency department. Factors associated with increased odds of emergency department use before cancer diagnosis included rurality (odds ratio [OR] 1.15, 95% confidence interval [CI] 1.13-1.17), residence in northern Ontario (North East region OR 1.14, 95% CI 1.10-1.17 and North West region OR 1.27, 95% CI 1.21-1.32, v. Toronto region), and living in the most marginalized areas (material resources OR 1.37, 95% CI 1.35-1.40 and housing OR 1.09, 95% CI 1.06-1.11, v. least marginalized quintile). We observed significant variation in emergency department use by cancer type, with high odds of emergency department use among patients with intracranial, pancreatic, liver or gallbladder, or thoracic cancer.

INTERPRETATION

Emergency department use is common before cancer diagnosis, with about one-third of patients with cancer in Ontario using the emergency department before diagnosis. Understanding why patients visit the emergency department before cancer diagnosis is important, particularly for patients who live in rural or marginalized areas, or those who have specific cancer types.

Exploring Factors That Prolong the Diagnosis of Myasthenia Gravis

Background and Objectives

Myasthenia gravis (MG) is a condition with significant phenotypic variability, posing a diagnostic challenge to many clinicians worldwide. Prolonged diagnosis can lead to reduced remission rates and morbidity. This study aimed to identify factors leading to a longer time to diagnosis in MG that could be addressed in future to optimize diagnosis time.

Methods

One hundred and ten patients from 3 institutions in Melbourne, Australia, were included in this retrospective cohort study. Demographic and clinical data were collected for these patients over the first 5 years from diagnosis and at 10 years. Nonparametric statistical analysis was used to identify factors contributing to a longer diagnosis time.

Results

The median time for MG diagnosis was 102 (345) days. 90% of patients were diagnosed before 1 year. Female patients took longer than male patients to be diagnosed (p = 0.013). The time taken for first presentation after symptom onset contributed most to diagnosis time (median 17 [141] days), with female patients and not working as contributory factors. Neurology referral took longer if patients had diplopia (p = 0.022), respiratory (p = 0.026) symptoms, or saw an ophthalmologist first (p < 0.001). Outpatient management compared with inpatient was associated with a longer time to be seen by a neurologist from referral (p < 0.001), for the first diagnostic result to return (p = 0.001), and for the result to be reviewed (p < 0.001). Ocular MG had a median greater time to neurologist review than generalized MG (median 5 [25] days vs 1 [13] days, p = 0.035). Electrophysiology tests took longer for outpatients than inpatients (median 21 [35] days vs 2 [8] days, p < 0.001). Outpatients were also started on treatment later than inpatients (p < 0.001). There was no association of MG severity, ethnicity, age, medical and ocular comorbidities, and public or private health service on diagnosis time. There was also no impact of time to diagnosis on Myasthenia Gravis Foundation of America outcomes, number of follow-ups or hospitalizations, or prevalence of treatments used. This study is limited by low patient numbers and its retrospective nature.

Discussion

This study identified several factors that can contribute to a prolonged diagnosis time of MG. Patient and clinician education about MG and outpatient diagnostic efficiency needs emphasis. Further studies are also needed to explore the delayed presentation time of women and nonworking patients in MG.

The Effectiveness and Cost-Effectiveness of Community Diagnostic Centres: A Rapid Review

Objectives: To examine the effectiveness of community diagnostic centres as a potential solution to increasing capacity and reducing pressure on secondary care in the UK. Methods: A comprehensive search for relevant primary studies was conducted in a range of electronic sources in August 2022. Screening and critical appraisal were undertaken by two independent reviewers. There were no geographical restrictions or limits to year of publication. A narrative synthesis approach was used to analyse data and present findings. Results: Twenty primary studies evaluating twelve individual diagnostic centres were included. Most studies were specific to cancer diagnosis and evaluated diagnostic centres located within hospitals. The evidence of effectiveness appeared mixed. There is evidence to suggest diagnostic centres can reduce various waiting times and reduce pressure on secondary care. However, cost-effectiveness may depend on whether the diagnostic centre is running at full capacity. Most included studies used weak methodologies that may be inadequate to infer effectiveness. Conclusion: Further well-designed, quality research is needed to better understand the effectiveness and cost-effectiveness of community diagnostic centres.

Potentially Avoidable Admissions and Prolonged Hospitalization in Patients with Suspected Colon Cancer

BACKGROUND

Suspicion of cancer in the Emergency Department (ED) may lead to potentially avoidable and prolonged admissions. We aimed to examine the reasons for potentially avoidable and prolonged hospitalizations after admissions from the ED for new colon cancer diagnoses (ED-dx).

METHODS

A retrospective, single-institution analysis was conducted of patients with ED-dx between 2017 and 2018. Defined criteria were used to identify potentially avoidable admissions. Patients without avoidable admissions were examined for ideal length of stay (iLOS), using separate defined criteria. Prolonged length of stay (pLOS) was defined as actual length of stay (aLOS) being greater than 1 day longer than iLOS.

RESULTS

Of 97 patients with ED-dx, 12% had potentially avoidable admissions, most often (58%) for cancer workup. Very little difference in demographic, tumor characteristics, or symptoms were found, except patients with potentially avoidable admissions were more functional (Eastern Cooperative Oncology Group [ECOG] score 0-1: 83% vs. 46%; p = 0.049) and had longer symptom duration prior to ED presentation {24 days (interquartile range [IQR] 7-75) vs. 7 days (IQR 2-21)}. Among the 60 patients who had necessary admissions but did not require urgent intervention, 78% had pLOS, most often for non-urgent surgery (60%) and further oncologic workup. The median difference between iLOS and aLOS was 12 days (IQR 8-16) for pLOS.

CONCLUSIONS

Potentially avoidable admissions following Ed-dx were uncommon but were mostly for oncologic workup. Once admitted, the majority of patients had pLOS, most often for definitive surgery and further oncologic workup. This suggests a lack of systems to safely transition to outpatient cancer management.

Return on investment of the lymphoma diagnostic pathway implementation in Alberta, Canada

The Lymphoma Diagnostic Pathway (LDP) was developed based upon clinical best practice guidelines and implemented in large urban centers where lymphoma treatment is provided in Alberta, Canada. A return-on-investment analysis of the implementation of this care pathway was conducted to inform future sustainability and expansion. A cohort design with propensity score matching and difference-in-difference estimation methods were used comparing both cost and return (reduced health service utilization) between patients who were diagnosed within the LDP and those who were diagnosed outside the LDP. LDP resulted in $1800 avoided HSU costs per patient. The LDP has been found to be cost-saving with an ROI of 5.3 (ranging from 3.95-8.97) - for every $1 invested, LDP resulted in a $5.30 return for the health system due to capacity improvements in ED, inpatient, outpatient, and a reduction in GP service utilization. Further study of implementation including patient/provider satisfaction and uptake is recommended.

Serum Chloride and Admission Status Are Potential Prognostic Markers of High-Risk Polyps: A Prospective Characterization of Colorectal Polyps in a Tertiary Hospital in Saudi Arabia

Background: Colorectal cancer (CRC) is the most common cancer in men in Saudi Arabia. Other than age and family history, clinical and laboratory prognostic surrogates that may aid in streamlining and prioritization of screening colonoscopies are scarce. Through the examination of the local prevalence of advanced and malignant colorectal polyps, we hypothesized that the presence of certain clinical or laboratory parameters may signify an association with having high-risk polyps.

Methods: A prospective study over a period of one year starting on January 21, 2018 and involving all adult patients undergoing colonoscopy at King Saud Medical City, Riyadh. Of the total 1,104 recruited patients, 717 were included. The patients were sub-grouped based on the presence or absence of polyps. Patients with polyps were further sub-grouped into high-risk or low-risk polyps. Comparisons between groups were performed using univariate, relative risks (RRs), and multivariate analyses.

Results: Our polyp detection rate was 34.7% and our adenoma detection rate was 21.3%. The prevalence of advanced adenoma was 15.2% and the prevalence of malignant polyps was 6.7%. Several prognostic markers were associated with high-risk polyps such as advanced age (RR = 1.35, 95% confidence interval [CI]: 1.03 to 1.78), male gender (RR = 1.18, 95% CI: 1.06 to 1.31), inpatient status (RR = 1.46, 95% CI: 1.04 to 2.21), and low serum chloride (RR = 1.89, 95% CI: 1.05 to 2.37). With multivariate analysis, the hazard ratios for inpatient status and hypochloremia were 1.67 (95% CI: 1.034 to 2.612) and 1.12 (95% CI: 1.011 to 1.265), respectively.

Conclusion: We report the prevalence of malignant colorectal polyps in Saudi Arabia which was not reported before. Two unique prognostic markers for high-risk polyps were identified, namely, inpatient status and hypochloremia.

The clinical and economic burden of peripheral T-cell lymphoma: a systematic literature review

Aim: To understand the burden of treatment-naive peripheral T-cell lymphoma (PTCL). Methods: A systematic literature review was conducted in November 2020 following best practice methodology. Results: Fifty-five clinical studies were included, mostly investigating cyclophosphamide, doxorubicin, vincristine and prednisone (CHOP) or 'CHOP-like' regimens, with combination regimens showing similar effectiveness to CHOP alone. Aside from the combination of brentuximab vedotin + cyclophosphamide, doxorubicin and prednisone (A+CHP), other available treatments showed no statistically significant benefit over CHOP in terms of overall or progression-free survival in overall PTCL patients. The mean monthly cost per patient in the USA ranged from $6328 to $9356 based on six studies. One economic evaluation demonstrated A+CHP to be a more cost-effective treatment option than CHOP. Conclusion: Further research is needed to understand the humanistic and cost impact of frontline treatment for PTCL and its specific subtypes.

Socioeconomic inequalities in treatment and relative survival among patients with diffuse large B-cell lymphoma: a Hong Kong population-based study

The influence of socioeconomic status (SES) on access to standard chemotherapy and/or monoclonal antibody therapy, and associated secular trends, relative survival, and excess mortality, among diffuse large B-cell lymphoma (DLBCL) patients is not clear. We conducted a Hong Kong population-based cohort study and identified adult patients with histologically diagnosed DLBCL between 2000 and 2018. We examined the association of SES levels with the odds and the secular trends of receipt of chemotherapy and/or rituximab. Additionally, we estimated the long-term relative survival by SES utilizing Hong Kong life tables. Among 4017 patients with DLBCL, 2363 (58.8%) patients received both chemotherapy and rituximab and 740 (18.4%) patients received chemotherapy alone, while 1612 (40.1%) and 914 (22.8%) patients received no rituximab or chemotherapy, respectively. On multivariable analysis, low SES was associated with lesser use of chemotherapy (odd ratio [OR] 0.44; 95% CI 0.34-0.57) and rituximab (OR 0.41; 95% CI 0.32-0.52). The socioeconomic disparity for either treatment showed no secular trend of change. Additionally, patients with low SES showed increased excess mortality, with a hazard ratio of 2.34 (95% CI 1.67-3.28). Improving survival outcomes for patients with DLBCL requires provision of best available medical care and securing access to treatment regardless of patients' SES.

Retrospective review of patients with lung cancer identified in the emergency department

BACKGROUND

Obtaining a diagnosis of cancer following an emergency department (ED) visit is associated with poor outcomes and advanced stage. Limited data is available from EDs in the United States. We describe a cohort of patients that obtained a diagnosis of lung cancer because of an ED visit.

METHODS

This is a single center, retrospective cohort of patients with lung cancer who presented to the ED between December 2016 and December 2019. We investigated demographics, access to primary care, previous cancer screening, cancer type/stage, mortality, and imaging study that suggested cancer. The primary outcome is the percentage of lung cancer diagnoses over a 4-year period that resulted from an ED visit.

RESULTS

Among the 268 patients with lung cancer, 152 patients (57.6%) had presented to the ED with a workup that was concerning for lung cancer. Patients were generally elderly (median 62-years old), African American (n = 77, 51%), and smokers (n = 145, 95.4%) with a median smoking pack years of 40. Only 24 patients (15.8%) had seen a primary care physician within 1 year of diagnosis, and only 8 patients were appropriately screened for lung cancer. The most common type of cancer was non-small-cell carcinoma (111, 73.0%), with 61.3% of those being adenocarcinoma (n = 68). Patients were most likely to be stage IV (n = 86, 56.6%), and the overall mortality was 53.3% (n = 81, 1 year follow-up). Most patients (88/152, 57.9%) of patients were admitted to the hospital, and Medicare patients (OR 2.7, 95% CI 1.37-5.23) and patients with stage IV disease (OR 2.22, 95% CI1.15-4.29) were more likely to be admitted. Patients were more likely to have a concerning finding on computed tomography (CT) versus chest x-ray (55.9% versus 36.8%, respectively). CT scan reports were more likely to mention malignancy (OR 5.9, 95% CI 2.5-14.0) or metastasis (OR 30, 95% CI 7.1-127.1) than chest x-ray.

CONCLUSION

Patients that have lung cancer diagnosed through the ED are more likely to be advanced stage at time of diagnosis and are more likely to have CT scans demonstrate concerning findings. Given the lack of previous cancer screening, the advanced stage at presentation of lung cancer to the ED, and high mortality rates, the ED may serve a public health role in addressing lung cancer screening.

Development of an algorithm for the identification of leukemic hematolymphoid neoplasms in Primary Care patients

BACKGROUND

Diagnosis of hematolymphoid neoplasm (HLN) requires different technologies which are performed on a patient basis instead of per protocol. We hypothesize that integration of hematimetric and cytological analysis along with multiparametric flow cytometry (MFC) provides a framework to evaluate peripheral blood (PB) samples from Primary Care.

METHODS

Samples from patients with persistent (>3 months) lymphocytosis (>5 × 109/L) and/or monocytosis (>109/L) or the presence of atypical and/or blast cells upon the smear review were analyzed by MFC concurrent to cytological analysis. MFC studies were carried out following standardized procedures.

RESULTS

In a 3-year period, smear review and MFC were performed simultaneously in 350 samples, demonstrating HLN in 194 cases (55.4%). In 156 cases, reactive cell populations were found. The combination of age, absolute lymphocyte count (ALC), hemoglobin and platelets provided the best correlation with MFC for the presence of a chronic lymphoproliferative disorder (CLPD) in lymphocytosis [area under the curve (AUC) 0.891, p < 0.05]. A model evaluating the probability of CLPD has been proposed and validated in an independent cohort.

CONCLUSIONS

A strategy to perform MFC studies following standardized procedures has proven to be useful to evaluate samples from patients in Primary Care centers for HLN diagnosis or reactive conditions, providing a sensitive and rapid clinical orientation and avoiding unnecessary consultations in routine clinical practice. The probability for the presence of CLPD in PB can be calculated and help guide decision-making regarding further testing.

The impact of Covid-19 on patients with suspected cancer: An analysis of ED presentation and referrals to a quick diagnosis unit

Purpose

Patients evaluated in the emergency department (ED) who have concerning symptoms suggestive of a cancer diagnosis are mostly referred to the quick diagnosis unit of our tertiary hospital. This study analyzed the impact of the Covid-19 pandemic on the volume, disease patterns, and accessibility to essential investigations of patients with suspected cancer referred by the ED to this unit.

Methods

Trends in referrals were analyzed from January 1 to July 8, 2020 and the corresponding dates of 2019. Only non-Covid-19 conditions were evaluated. Three time-based cohorts were defined: prepandemic (January 1–February 19), pandemic (February 19–April 22), and postpandemic (April 22–July 8). Along with descriptive statistics, linear regression was used to test for time trends with weekly referrals as the dependent variable.

Results

There were 384, 193, and 450 patients referred during the prepandemic, pandemic, and postpandemic periods, respectively. Following an increasing rate, referrals decreased to unprecedented levels in the pandemic period (average weekly slope: −2.1 cases), then increasing again until near normalization. Waiting times to most diagnostic procedures including radiology, endoscopic, nuclear medicine, and biopsy/cytology during the pandemic period were significantly delayed and time-to-diagnosis was considerably longer (19.72 ± 10.37 days vs. 8.33 ± 3.94 days in prepandemic and 13.49 ± 6.45 days in postpandemic period; P < 0.001 in both). Compared to other cohorts, pandemic cohort patients were more likely to have unintentional weight loss and fever of unknown origin as referral indications while anemia and lymphadenopathy were less common. Patients from the pandemic cohort had a significantly lower rate of malignancies and higher of benign gastrointestinal disorders (40.93% vs. 19.53% and 20.89% in prepandemic and postpandemic periods, respectively; P < 0.001 in both), most notably irritable bowel disease, and of mental and behavioral disorders (15.54% vs. 3.39% and 6.00% in prepandemic and postpandemic periods, respectively; P < 0.001 in both).

Conclusions

As our hospital switched its traditional care to one focused on Covid-19 patients, recognized indicators of healthcare quality of quick diagnosis units were severely disrupted. The clinical patterns of presentation and diagnosis of the pandemic period suggested that mass media-generated mental and behavioral responses with distressing symptoms played a significant role in most of these patients.

A comparative cost analysis between two quick diagnosis units of different levels of complexity

Aim: To compare by micro-costing the costs incurred by quick diagnosis units of tertiary and second-level hospitals. Patients & methods: We included 407 patients from a tertiary and secondary hospital unit. A bottom-up approach was applied. Results: Cost per patient was €577.5 ± 219.6 in the tertiary versus €394.7 ± 92.58 in the secondary unit (p = 0.0559). Mean number of visits and ratio of successive/first visits were significantly higher in the former (3.098 and 2.07 vs 2.123 and 1.12, respectively). Personnel and indirect costs including their percent contribution to overall costs accounted for the main differences. Conclusion: A greater volume of appointments, number of staff and staff time and a greater complexity of patients from the tertiary hospital unit justified the differences in cost outcomes.

Trends in Hospitalization of Patients with Potentially Serious Diseases Evaluated at a Quick Diagnosis Clinic

Although quick diagnosis units (QDU) have become a cost-effective alternative to inpatient admission for diagnosis of potentially serious diseases, the rate of return hospitalizations among evaluated patients is unknown. This study examined the temporal trends in admissions of QDU patients through 15 years. Adult patients referred to QDU from 2004 to 2019 who were hospitalized between the first and last visit in the unit were eligible. Decisions about admissions were mainly based on the Appropriateness Evaluation Protocol and required independent validation by experienced clinicians using a customized tool. The final analysis included 825 patients. Patient characteristics and major reasons for admission were compared each year and linear trends were analyzed. Admission rates decreased from 7.2% in 2004–2005 to 4.3% in 2018–2019 (p < 0.0001). While a significant increasing trend was observed in the rate of admissions due to cancer-related complications (from 39.5% in 2004–2005 to 61.7% in 2018–2019; p < 0.0001), those due to anemia-related complications and scheduled invasive procedures experienced a significant downward trend. A likely explanation for these declining trends was the relocation of the unit to a new daycare center in 2013–2014 with recovery rooms and armchairs for IV treatments. The facts of this study could help in the provision of anticipatory guidance for the optimal management of patients at risk of clinical complications.

What is the relevance of an ambulatory quick diagnosis unit or inpatient admission for the diagnosis of pancreatic cancer? A retrospective study of 1004 patients

Quick diagnosis units (QDU) have become an alternative hospital-based ambulatory medicine strategy to inpatient hospitalization for potentially serious illnesses in Spain. Whether diagnosis of pancreatic cancer is better accomplished by an ambulatory or inpatient approach is unknown. The main objective of this retrospective study was to examine and compare the diagnostic effectiveness of a QDU or inpatient setting in patients with pancreatic cancer.Patients with a diagnosis of pancreatic adenocarcinoma who had been referred to a university, tertiary hospital-based QDU or hospitalized between 2005 and 2018 were eligible. Presenting symptoms and signs, risk and prognostic factors, and time to diagnosis were compared. The costs incurred during the diagnostic assessment were analyzed with a microcosting method.A total of 1004 patients (508 QDU patients and 496 inpatients) were eligible. Admitted patients were more likely than QDU patients to have weight loss, asthenia, anorexia, abdominal pain, jaundice, and palpable hepatomegaly. Time to diagnosis of inpatients was similar to that of QDU patients (4.1 [0.8 vs 4.3 [0.6] days; P = .163). Inpatients were more likely than QDU patients to have a tumor on the head of the pancreas, a tumor size >2 cm, a more advanced nodal stage, and a poorer histological differentiation. No differences were observed in the proportion of metastatic and locally advanced disease and surgical resections. Microcosting revealed a cost of &OV0556;347.76 (48.69) per QDU patient and &OV0556;634.36 (80.56) per inpatient (P < .001).Diagnosis of pancreatic cancer is similarly achieved by an inpatient or QDU clinical approach, but the latter seems to be cost-effective. Because the high costs of hospitalization, an ambulatory diagnostic assessment may be preferable in these patients.

Pulmonary Presentation of Kaposi-Sarcoma in a Renal Transplant Recipient

Renal transplant patients on immunosuppression are at risk for malignancy. One form of malignancy that commonly affects this population is Kaposi-sarcoma. Kaposi-sarcoma is a human herpesvirus-8 (HHV-8)-driven process classically associated with skin lesions in immunocompromised patients. The pulmonary system may be involved in disseminated disease. In this case, a renal transplant patient was re-admitted with acute hypoxic respiratory failure and hemoptysis of an unclear etiology. Following a broad workup, HHV-8 PCR and a lymph node biopsy confirmed pulmonary Kaposi-sarcoma. Workup for multicentric Castleman disease was negative. The patient was treated with liposomal doxorubicin, ganciclovir, and prednisone. Her immunosuppression was changed to sirolimus and she is scheduled to complete six cycles of liposomal doxorubicin.

Evaluation of Lymphadenopathy and Suspected Lymphoma in a Lymphoma Rapid Diagnosis Clinic

PURPOSE

Lymphomas often present a diagnostic challenge, and for some a delay in diagnosis can negatively influence outcomes of therapy. We established a nurse practitioner-led lymphoma rapid diagnosis clinic (LRDC) with the goal of reducing wait times to definitive diagnosis. We examined the initial 30-month experience of the LRDC, and results were compared with time periods before implementation of the clinic to determine program impact.

METHODS

All patients referred to LRDC with suspicion of lymphoma from June 1, 2015 to Nov 30, 2017 were evaluated. Time from initial consultation to diagnosis was compared with patients diagnosed at our center with lymphoma in 2008 and 2012. Patient symptoms and relevant laboratory/imaging findings were collected to identify patterns of presentation and predictive factors for benign diagnoses.

RESULTS

Of the 126 patients evaluated, 66 (52%) had confirmation of lymphoma diagnosis. Median time to lymphoma diagnosis was 16 days for patients assessed in LRDC and 28 days for historical controls (P < .001). By univariable analysis, lymph node size greater than 3.4 cm and presence of mediastinal or abdominal adenopathy increased the likelihood of a diagnosis of malignancy, whereas younger age, being a nonsmoker, and prior rheumatologic condition were associated with a nonmalignant diagnosis. In multivariable analysis, lymph node size, age, and prior rheumatologic diagnosis remained significant.

CONCLUSION

Establishing a nurse practitioner-led LRDC was effective in shortening time to diagnosis of lymphoma. Younger age, smaller lymph node size, and prior rheumatologic disorder reduced the likelihood of a cancer diagnosis in our patient population.