1
|
Liedberg F, Gårdmark T, Hagberg O, Aljabery F, Ströck V, Hosseini A, Malmström PU, Söderkvist K, Ullén A, Jerlström T, Jahnson S, Holmberg L, Häggström C. Treatment Related to Urinary Tract Infections Is Associated with Delayed Diagnosis of Urinary Bladder Cancer: A Nationwide Population-based Study. Eur Urol Oncol 2024:S2588-9311(24)00181-0. [PMID: 39143001 DOI: 10.1016/j.euo.2024.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 06/12/2024] [Accepted: 07/08/2024] [Indexed: 08/16/2024]
Abstract
BACKGROUND AND OBJECTIVE It has been suggested that urinary tract infections (UTIs) are associated with delayed diagnosis of bladder cancer (BC). Our aim was to investigate prediagnostic treatments related to UTI and the relation to BC diagnostic delay, reflected by advanced disease at diagnosis. METHODS We used data from the BladderBaSe 2.0 with data of treatments related to UTI up to 3 yr before BC diagnosis (2008-2019) for BC patients in comparison to a matched reference population. We investigated the association between UTI treatments and more advanced disease at diagnosis in the BC cohort. We used generalized ordered logistic regression to calculate odds ratios (ORs) for more advanced disease as an ordered outcome: non-muscle-invasive BC (NMIBC), muscle-invasive BC (MIBC), and metastatic BC (MBC). KEY FINDINGS AND LIMITATIONS The study population included 29 921 BC patients and 149 467 matched reference subjects. The proportions of individuals receiving UTI treatment were higher in the patient groups than in the corresponding reference groups, with the greatest differences observed for the MIBC and MBC subgroups. The OR for the risk of more advanced disease (MIBC or MBC) with at least one UTI treatment versus none was 1.28 (95% confidence interval [CI] 1.19-1.37) for men and 1.42 (95 % CI 1.27-1.58) for women. The association to risk of more advanced disease increased with the number of UTI treatments for both sexes. CONCLUSIONS AND CLINICAL IMPLICATIONS Further studies on the effects of treatments related to UTI in combination with other factors are needed to identify reasons for possible delays in the BC diagnostic pathway. PATIENT SUMMARY We found that for patients with bladder cancer, previous antibiotic treatment for a urinary tract infection was linked to more advanced disease at diagnosis. Further studies are needed to identify reasons for possible delays in the diagnosis of bladder cancer.
Collapse
Affiliation(s)
- Fredrik Liedberg
- Department of Translational Medicine, Lund University, Malmö, Sweden; Department of Urology, Skåne University Hospital, Malmö, Sweden
| | - Truls Gårdmark
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institute, Stockholm, Sweden
| | - Oskar Hagberg
- Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Firas Aljabery
- Department of Clinical and Experimental Medicine, Division of Urology, Linköping University, Linköping, Sweden
| | - Viveka Ströck
- Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Abolfazl Hosseini
- Department of Urology, Karolinska University Hospital, Stockholm, Sweden
| | - Per-Uno Malmström
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Karin Söderkvist
- Department of Diagnostics and Intervention, Oncology, Umeå University, Umeå, Sweden
| | - Anders Ullén
- Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden; Department of Pelvic Cancer, Genitourinary Oncology and Urology Unit, Karolinska University Hospital, Stockholm, Sweden
| | - Tomas Jerlström
- Department of Urology, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Staffan Jahnson
- Department of Clinical and Experimental Medicine, Division of Urology, Linköping University, Linköping, Sweden
| | - Lars Holmberg
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden; Translational Oncology & Urology Research, School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - Christel Häggström
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden; Northern Registry Centre, Department of Diagnostics and Intervention, Umeå University, Umeå, Sweden.
| |
Collapse
|
2
|
Zhou Y, Lyratzopoulos G, Rajan P, Walter FM, Wu J. Understanding symptom contribution to sex inequality in bladder and renal cancer stage at diagnosis. BJUI COMPASS 2024; 5:691-698. [PMID: 39022664 PMCID: PMC11249815 DOI: 10.1002/bco2.360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 03/25/2024] [Indexed: 07/20/2024] Open
Abstract
Background Understanding sex-specific factors contributing to advanced-stage diagnosis can guide interventions to reduce sex inequality in patients with urological cancers. Method We used linked primary care and cancer registry data to examine associations between symptoms and advanced-stage in 1151 bladder cancer and 440 renal cancer patients diagnosed between January 2012 and December 2015 in England. We performed logistic regression, adjusting for sex, age, deprivation and routes to diagnosis, including interaction terms between symptoms and sex and symptoms and age. Results Female sex (OR vs. men 1.89 [1.28-2.79]; p = 0.001) and patients presenting with urinary tract infections (OR 2.22 [1.34-3.69]) and abdominal symptoms (OR 2.19 [1.30-3.70]) were associated with increased odds of advanced-stage bladder cancer (vs. haematuria, p = 0.016 for both). Women with haematuria and men with abdominal symptoms (compared with the opposite sex with the same presenting symptom) were more likely to have advanced-stage bladder cancer. Neither sex nor symptom associations were observed for renal cancer. Conclusion Non-haematuria symptoms are associated with higher risk of advanced-stage bladder cancer. Greater risk of advanced-stage bladder cancer in women may reflect biological differences in haematuria onset and sex differences during diagnostic process. Identifying higher risk women with haematuria may reduce sex inequalities in bladder cancer outcomes.
Collapse
Affiliation(s)
- Yin Zhou
- Wolfson Institute of Population HealthQueen Mary University of LondonLondonUK
| | | | - Prabhakar Rajan
- Barts Cancer Institute, Cancer Research UK City of London CentreQueen Mary University of LondonLondonUK
- Department of Urology, Barts Health NHS TrustThe Royal London HospitalLondonUK
| | - Fiona M. Walter
- Wolfson Institute of Population HealthQueen Mary University of LondonLondonUK
| | - Jianhua Wu
- Wolfson Institute of Population HealthQueen Mary University of LondonLondonUK
| |
Collapse
|
3
|
Lavu D, Khan A, Konya J, Martins T, Price S, Neal R. Gender inequalities across ethnicities in primary care cancer referrals: a scoping review protocol. BJGP Open 2024; 8:BJGPO.2023.0211. [PMID: 38331467 PMCID: PMC11300982 DOI: 10.3399/bjgpo.2023.0211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 01/19/2024] [Accepted: 01/29/2024] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND Early cancer diagnosis is associated with improved mortality and morbidity; however, studies indicate that women and individuals from ethnic minorities experience longer times to diagnosis and worse prognosis compared with their counterparts for various cancers. In countries with a gatekeeper healthcare system, such as the UK, most suspected cancer referrals are initiated in primary care. AIM To understand the extent of evidence available on the relationship between primary care cancer referral pathways and cancer outcomes in relation to gender across different ethnic groups. This will identify research gaps and enable development of strategies to ease potential inequalities in cancer diagnosis. DESIGN & SETTING A scoping review of articles written in English, based on the Joanna Briggs Institute methodology. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) will be used. METHOD Electronic databases and private collections of the team members will be searched for studies. Two independent reviewers will carry out the study selection and data extraction. Based on Population (or participants), Concept, and Context (PCC) framework, this review will consider studies after year 2000, which explored the relationship between gender, across various ethnic groups, and cancer outcomes, following primary care cancer referral in countries with gatekeeper healthcare systems (UK, New Zealand, Sweden, Australia, Canada, Denmark, Republic of Ireland, and Norway). Results will be presented as a narrative analysis. CONCLUSION The results are expected to provide an overview of the discrepancies in primary care cancer referrals based on gender across ethnic groups, which will be crucial to define an appropriate range of strategies to ease any inequalities in primary healthcare cancer diagnosis.
Collapse
Affiliation(s)
- Deepthi Lavu
- APEx (Exeter Collaboration for Academic Primary Care), Department of Health and Community Sciences, Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Adnan Khan
- APEx (Exeter Collaboration for Academic Primary Care), Department of Health and Community Sciences, Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Judit Konya
- APEx (Exeter Collaboration for Academic Primary Care), Department of Health and Community Sciences, Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Tanimola Martins
- APEx (Exeter Collaboration for Academic Primary Care), Department of Health and Community Sciences, Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Sarah Price
- APEx (Exeter Collaboration for Academic Primary Care), Department of Health and Community Sciences, Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Richard Neal
- APEx (Exeter Collaboration for Academic Primary Care), Department of Health and Community Sciences, Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| |
Collapse
|
4
|
Tan WS, Ahmad A, Zhou Y, Nathan A, Ogunbo A, Gbolahan O, Kallam N, Smith R, Khalifeh M, Tan WP, Cohen D, Volanis D, Walter FM, Sasieni P, Kamat AM, Kelly JD. Hematuria Cancer Risk Score with Ultrasound Informs Cystoscopy Use in Patients with Hematuria. Eur Urol Oncol 2024:S2588-9311(24)00134-2. [PMID: 38811250 DOI: 10.1016/j.euo.2024.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 04/04/2024] [Accepted: 05/07/2024] [Indexed: 05/31/2024]
Abstract
BACKGROUND Hematuria is a cardinal symptom of urinary tract cancer and would require further investigations. OBJECTIVE To determine the ability of renal bladder ultrasound (RBUS) with the Hematuria Cancer Risk Score (HCRS) to inform cystoscopy use in patients with hematuria. DESIGN, SETTING, AND PARTICIPANTS The development cohort comprised 1984 patients with hematuria from 40 UK hospitals (DETECT 1; ClinicalTrials.gov: NCT02676180) who received RBUS. An independent validation cohort comprised 500 consecutive patients referred to secondary care for a suspicion of bladder cancer. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Sensitivity and true negative of the HCRS and RBUS were assessed. RESULTS AND LIMITATIONS A total of 134 (7%) and 36 (8%) patients in the development and validation cohorts, respectively, had a diagnosis of urinary tract cancer. Validation of the HCRS achieves good discrimination with an area under the receiver operating characteristic curve of 0.727 (95% confidence interval 0.648-0.800) in the validation cohort with sensitivity of 95% for the identification of cancer. Utilizing the cutoff of 4.500 derived from the HCRS in combination with RBUS in the development cohort, 680 (34%) patients would have been spared cystoscopy at the cost of missing a G1 Ta bladder cancer and a urinary tract cancer patient, while 117 (25%) patients would have avoided cystoscopy at the cost of missing a single patient of G1 Ta bladder cancer with sensitivity for the identification of cancer of 97% in the validation cohort. CONCLUSIONS The HCRS with RBUS offers good discriminatory ability in identifying patients who would benefit from cystoscopy, sparing selected patient cohorts from an invasive procedure. PATIENT SUMMARY The hematuria cancer risk score with renal bladder ultrasound allows for the triage of patients with hematuria who would benefit from visual examination of the bladder (cystoscopy). This resulted in 25% of patients safely omitting cystoscopy, which is an invasive procedure, and would lead to health care cost savings.
Collapse
Affiliation(s)
- Wei Shen Tan
- Department of Urology, University of Texas MD Anderson Cancer Centre, Houston, TX, USA; Division of Surgery and Interventional Science, University College London, London, UK.
| | - Amar Ahmad
- Division of Surgery and Interventional Science, University College London, London, UK; Cancer Intelligence, Cancer Research UK, London, UK
| | - Yin Zhou
- Department of Public health and Primary Care, University of Cambridge, Cambridge, UK; Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Arjun Nathan
- Department of Urology, University of Texas MD Anderson Cancer Centre, Houston, TX, USA; Department of Urology, Royal Free Hospital, London, UK
| | | | | | - Neha Kallam
- Department of Urology, Royal Free Hospital, London, UK
| | - Rebecca Smith
- Department of Urology, Royal Free Hospital, London, UK
| | - Maen Khalifeh
- Department of Urology, Royal Free Hospital, London, UK
| | - Wei Phin Tan
- Department of Urology, New York University Langone Health, New York City, NY, USA
| | - Daniel Cohen
- Department of Urology, Royal Free Hospital, London, UK
| | | | - Fiona M Walter
- Department of Public health and Primary Care, University of Cambridge, Cambridge, UK; Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Peter Sasieni
- Faculty of Life Sciences & Medicine, School of Cancer & Pharmaceutical Sciences, Innovation Hub, Guys Cancer Centre, Guys Hospital, King's College London, London, UK
| | - Ashish M Kamat
- Division of Surgery and Interventional Science, University College London, London, UK
| | - John D Kelly
- Division of Surgery and Interventional Science, University College London, London, UK; Department of Urology, University College London Hospitals, London, UK
| |
Collapse
|
5
|
Toren P, Wilkins A, Patel K, Burley A, Gris T, Kockelbergh R, Lodhi T, Choudhury A, Bryan RT. The sex gap in bladder cancer survival - a missing link in bladder cancer care? Nat Rev Urol 2024; 21:181-192. [PMID: 37604983 DOI: 10.1038/s41585-023-00806-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2023] [Indexed: 08/23/2023]
Abstract
The differences in bladder cancer outcomes between the sexes has again been highlighted. Uncommon among cancers, bladder cancer outcomes are notably worse for women than for men. Furthermore, bladder cancer is three to four times more common among men than among women. Factors that might explain these sex differences include understanding the importance of haematuria as a symptom of bladder cancer by both clinicians and patients, the resultant delays in diagnosis and referral of women with haematuria, and health-care access. Notably, these factors seem to have geographical variation and are not consistent across all health-care systems. Likewise, data relating to sex-specific treatment responses for patients with non-muscle-invasive or muscle-invasive bladder cancer are inconsistent. The influence of differences in the microbiome, bladder wall thickness and urine dwell times remain to be elucidated. The interplay of hormone signalling, gene expression, immunology and the tumour microenvironment remains complex but probably underpins the sexual dimorphism in disease incidence and stage and histology at presentation. The contribution of these biological phenomena to sex-specific outcome differences is probable, albeit potentially treatment-specific, and further understanding is required. Notwithstanding these aspects, we identify opportunities to harness biological differences to improve treatment outcomes, as well as areas of fundamental and translational research to pursue. At the level of policy and health-care delivery, improvements can be made across the domains of patient awareness, clinician education, referral pathways and guideline-based care. Together, we aim to highlight opportunities to close the sex gap in bladder cancer outcomes.
Collapse
Affiliation(s)
- Paul Toren
- CHU de Québec-Université Laval, Quebec City, Quebec, Canada
| | - Anna Wilkins
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
- The Royal Marsden Hospitals NHS Trust, London, UK
| | - Keval Patel
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Amy Burley
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
| | - Typhaine Gris
- CHU de Québec-Université Laval, Quebec City, Quebec, Canada
| | - Roger Kockelbergh
- University Hospitals of Leicester NHS Trust, Leicester, UK
- Action Bladder Cancer UK, Tetbury, UK
| | - Taha Lodhi
- Division of Cancer Sciences, University of Manchester and The Christie NHS Foundation Trust, Manchester, UK
| | - Ananya Choudhury
- Division of Cancer Sciences, University of Manchester and The Christie NHS Foundation Trust, Manchester, UK
| | - Richard T Bryan
- Action Bladder Cancer UK, Tetbury, UK.
- Bladder Cancer Research Centre, Institute of Cancer & Genomic Sciences, University of Birmingham, Birmingham, UK.
| |
Collapse
|
6
|
Funston G, Moullet M, Mounce L, Lyratzopoulos G, Walter FM, Zhou Y. Pre-diagnostic prescription patterns in bladder and renal cancer: a longitudinal linked data study. Br J Gen Pract 2023; 74:BJGP.2023.0122. [PMID: 38164573 PMCID: PMC10764107 DOI: 10.3399/bjgp.2023.0122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 07/14/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND Understanding pre-diagnostic prescribing activity could reveal windows during which more timely cancer investigation and detection may occur. AIM To examine prescription patterns for common urological clinical features prior to renal and bladder cancer diagnoses. DESIGN AND SETTING A retrospective cohort study was performed using electronic primary care and cancer registry data on patients with bladder and renal cancer, who received their diagnosis between April 2012 and December 2015 in England. METHOD Primary care prescriptions up to 2 years pre- diagnosis were analysed for five groups of clinical features (irritative urological symptoms, obstructive symptoms, urinary tract infections [UTIs], genital infections, and atrophic vaginitis). Poisson regressions estimating the inflection point from which the rate of prescriptions increased from baseline were used to identify the start of diagnostic windows during which cancer could be detected. RESULTS A total of 48 094 prescriptions for 5322 patients were analysed. Inflection points for an increase in UTI prescriptions were identified 9 months pre- diagnosis for renal (95% confidence interval [CI] = 5.3 to 12.7) and bladder (95% CI = 7.4 to 10.6) cancers. For bladder cancer, the change in UTI antibiotic prescription rates occurred 4 months earlier in females (11 months pre- diagnosis, 95% CI = 9.7 to 12.3) than in males (7 months pre-diagnosis, 95% CI = 5.4 to 8.6). For other clinical features, no inflection points were identified and, as such, no diagnostic windows could be defined. CONCLUSION Prescription rates for UTIs increased 9 months before bladder and renal cancer diagnoses, indicating that there is potential to expedite diagnosis of these cancers in patients presenting with features of UTI. The greatest opportunity for more timely diagnosis may be in females with bladder cancer, who experienced the earliest increase in UTI prescription rate.
Collapse
Affiliation(s)
- Garth Funston
- Department of Public Health and Primary Care, University of Cambridge, Cambridge; Wolfson Institute of Population Health, Queen Mary University of London, London
| | - Marie Moullet
- Wolfson Institute of Population Health, Queen Mary University of London, London
| | - Luke Mounce
- University of Exeter Medical School, University of Exeter, Exeter
| | | | - Fiona M Walter
- Wolfson Institute of Population Health, Queen Mary University of London, London
| | - Yin Zhou
- Department of Public Health and Primary Care, University of Cambridge, Cambridge; Wolfson Institute of Population Health, Queen Mary University of London, London
| |
Collapse
|
7
|
Zhou Y, Singh H, Hamilton W, Archer S, Tan S, Brimicombe J, Lyratzopoulos G, Walter FM. Improving the diagnostic process for patients with possible bladder and kidney cancer: a mixed-methods study to identify potential missed diagnostic opportunities. Br J Gen Pract 2023; 73:e575-e585. [PMID: 37253628 PMCID: PMC10242858 DOI: 10.3399/bjgp.2022.0602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 02/03/2023] [Accepted: 02/28/2023] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND Patients with bladder and kidney cancer may experience diagnostic delays. AIM To identify patterns of suboptimal care and contributors of potential missed diagnostic opportunities (MDOs). DESIGN AND SETTING Prospective, mixed-methods study recruiting participants from nine general practices in Eastern England between June 2018 and October 2019. METHOD Patients with possible bladder and kidney cancer were identified using eligibility criteria based on National Institute for Health and Care Excellence (NICE) guidelines for suspected cancer. Primary care records were reviewed at recruitment and at 1 year for data on symptoms, tests, referrals, and diagnosis. Referral predictors were examined using logistic regression. Semi-structured interviews were undertaken with 15 patients to explore their experiences of the diagnostic process, and these were analysed thematically. RESULTS Participants (n = 940) were mostly female (n = 657, 69.9%), with a median age of 71 years (interquartile range 64-77 years). In total, 268 (28.5%) received a referral and 465 (48.5%) had a final diagnosis of urinary tract infection (UTI). There were 33 (3.5%) patients who were diagnosed with cancer, including prostate (n = 17), bladder (n = 7), and upper urothelial tract (n = 1) cancers. Among referred patients, those who had a final diagnosis of UTI had the longest time to referral (median 81.5 days). Only one-third of patients with recurrent UTIs were referred despite meeting NICE referral guidelines. Qualitative findings revealed barriers during the diagnostic process, including inadequate clinical examination, female patients given repeated antibiotics without clinical reviews, and suboptimal communication of test results to patients. CONCLUSION Older females with UTIs might be at increased risk of MDOs for cancer. Targeting barriers during the initial diagnostic assessment and follow-up might improve quality of diagnosis.
Collapse
Affiliation(s)
- Yin Zhou
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX, US
| | | | - Stephanie Archer
- Department of Public Health and Primary Care, University of Cambridge, Cambridge and Department of Psychology, University of Cambridge, Cambridge, UK
| | - Sapphire Tan
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - James Brimicombe
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Georgios Lyratzopoulos
- Epidemiology of Cancer Healthcare and Outcomes (ECHO), Department of Behavioural Science and Health, Institute of Epidemiology and Health Care (IEHC), University College London, London, UK
| | - Fiona M Walter
- Department of Public Health and Primary Care, University of Cambridge, Cambridge and Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| |
Collapse
|
8
|
Papavasiliou E, Sills VA, Calanzani N, Harrison H, Snudden C, di Martino E, Cowan A, Behiyat D, Boscott R, Tan S, Bovaird J, Stewart GD, Walter FM, Zhou Y. Diagnostic Performance of Biomarkers for Bladder Cancer Detection Suitable for Community and Primary Care Settings: A Systematic Review and Meta-Analysis. Cancers (Basel) 2023; 15:709. [PMID: 36765672 PMCID: PMC9913596 DOI: 10.3390/cancers15030709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 01/13/2023] [Accepted: 01/17/2023] [Indexed: 01/26/2023] Open
Abstract
Evidence on the use of biomarkers to detect bladder cancer in the general population is scarce. This study aimed to systematically review evidence on the diagnostic performance of biomarkers which might be suitable for use in community and primary care settings [PROSPERO Registration: CRD42021258754]. Database searches on MEDLINE and EMBASE from January 2000 to May 2022 resulted in 4914 unique citations, 44 of which met inclusion criteria. Included studies reported on 112 biomarkers and combinations. Heterogeneity of designs, populations and outcomes allowed for the meta-analysis of three biomarkers identified in at least five studies (NMP-22, UroVysion, uCyt+). These three biomarkers showed similar discriminative ability (adjusted AUC estimates ranging from 0.650 to 0.707), although for NMP-22 and UroVysion there was significant unexplained heterogeneity between included studies. Narrative synthesis revealed the potential of these biomarkers for use in the general population based on their reported clinical utility, including effects on clinicians, patients, and the healthcare system. Finally, we identified some promising novel biomarkers and biomarker combinations (N < 3 studies for each biomarker/combination) with negative predictive values of ≥90%. These biomarkers have potential for use as a triage tool in community and primary care settings for reducing unnecessary specialist referrals. Despite promising emerging evidence, further validation studies in the general population are required at different stages within the diagnostic pathway.
Collapse
Affiliation(s)
- Evie Papavasiliou
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge CB1 8RN, UK
| | - Valerie A. Sills
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge CB1 8RN, UK
| | - Natalia Calanzani
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge CB1 8RN, UK
| | - Hannah Harrison
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge CB2 0SR, UK
| | - Claudia Snudden
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge CB1 8RN, UK
| | - Erica di Martino
- Division of Primary Care, Public Health & Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds LS2 3AA, UK
| | - Andy Cowan
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge CB1 8RN, UK
| | - Dawnya Behiyat
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge CB1 8RN, UK
| | - Rachel Boscott
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge CB1 8RN, UK
| | - Sapphire Tan
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge CB1 8RN, UK
| | - Jennifer Bovaird
- Patient & Public Representative c/o The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge CB1 8RN, UK
| | - Grant D. Stewart
- Department of Surgery, University of Cambridge, Cambridge Biomedical Campus, Cambridge CB2 0QQ, UK
| | - Fiona M. Walter
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge CB1 8RN, UK
- Wolfson Institute of Population Health, Barts and The London School of Medicine and Dentistry Queen Mary University of London, London EC1M 6BQ, UK
| | - Yin Zhou
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge CB1 8RN, UK
| |
Collapse
|
9
|
Abuhasanein S, Jahnson S, Aljabery F, Gårdmark T, Jerlström T, Liedberg F, Sherif A, Ströck V, Kjölhede H. Standardized care pathways for patients with suspected urinary bladder cancer: the Swedish experience. Scand J Urol 2022; 56:227-232. [PMID: 35389306 DOI: 10.1080/21681805.2022.2058605] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES To compare time intervals to diagnosis and treatment, tumor characteristics, and management in patients with primary urinary bladder cancer, diagnosed before and after the implementation of a standardized care pathway (SCP) in Sweden. MATERIALS AND METHODS Data from the Swedish National Register of Urinary Bladder Cancer was studied before (2011-2015) and after (2016-2019) SCP. Data about time from referral to transurethral resection of bladder tumor (TURBT), patients and tumor characteristics, and management were analyzed. Subgroup analyses were performed for cT1 and cT2-4 tumors. RESULTS Out of 26,795 patients, median time to TURBT decreased from 37 to 27 days after the implementation of SCP. While the proportion of cT2-T4 tumors decreased slightly (22-21%, p < 0.001), this change was not stable over time and the proportions cN + and cM1 remained unchanged. In the subgroups with cT1 and cT2-4 tumors, the median time to TURBT decreased and the proportions of patients discussed at a multidisciplinary team conference (MDTC) increased after SCP. In neither of these subgroups was a change in the proportions of cN + and cM1 observed, while treatment according to guidelines increased after SCP in the cT1 group. CONCLUSION After the implementation of SCP, time from referral to TURBT decreased and the proportion of patients discussed at MDTC increased, although not at the levels recommended by guidelines. Thus, our findings point to the need for measures to increase adherence to SCP recommendations and to guidelines.
Collapse
Affiliation(s)
- Suleiman Abuhasanein
- Department of Urology, Institute of Clinical Science, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden.,Department of Surgery, Urology Section, NU Hospital Group, Trollhättan, Sweden
| | - Staffan Jahnson
- Department of Clinical and Experimental Medicine, Division of Urology, Linköping University, Linköping, Sweden
| | - Firas Aljabery
- Department of Clinical and Experimental Medicine, Division of Urology, Linköping University, Linköping, Sweden
| | - Truls Gårdmark
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institute, Stockholm, Sweden
| | - Tomas Jerlström
- Department of Urology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Fredrik Liedberg
- Department of Urology, Skåne University Hospital, Malmö, Sweden.,Institution of Translational Medicine, Lund University, Malmö, Sweden
| | - Amir Sherif
- Department of Surgical and Perioperative Sciences, Urology and Andrology, Umeå University, Umeå, Sweden
| | - Viveka Ströck
- Department of Urology, Institute of Clinical Science, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden.,Department of Urology, Sahlgrenska University Hospital, Region Västra Götaland, Göteborg, Sweden
| | - Henrik Kjölhede
- Department of Urology, Institute of Clinical Science, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden.,Department of Urology, Sahlgrenska University Hospital, Region Västra Götaland, Göteborg, Sweden
| |
Collapse
|
10
|
Pre-diagnostic clinical features and blood tests in patients with colorectal cancer: a retrospective linked data study. Br J Gen Pract 2022; 72:e556-e563. [PMID: 35667682 PMCID: PMC9183460 DOI: 10.3399/bjgp.2021.0563] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 02/21/2022] [Indexed: 10/31/2022] Open
Abstract
Background: The majority of colorectal cancer cases are diagnosed following symptomatic presentation in the United Kingdom. Aim: To identify windows of opportunity for timely investigations or referrals in patients presenting with colon and rectal cancer-relevant symptoms or abnormal blood tests. Design and setting: Retrospective cohort study using linked primary care and cancer registry data of colorectal cancer patients diagnosed in England between 2012-2015. Methods: Monthly consultation rates for relevant clinical features (change in bowel habit, rectal bleeding, abdominal pain, mass, constitutional symptoms, and other bowel symptoms) and abnormal blood test results (low haemoglobin, high platelets and inflammatory markers) up to 24 months pre-diagnosis were calculated. Poisson regression adjusted for age, sex and relevant comorbidities was used to estimate the most likely month when consultation rates increased above baseline trend. Results: 5033 colon and 2516 rectal cancer patients were included. Consultations for all examined clinical features and abnormal blood tests increased in the year pre-diagnosis. Rectal bleeding was the earliest clinical feature to increase from baseline rate: 10 months (95%CI 8.3-11.7) pre-diagnosis for colon cancer; 8 months (95%CI 6.1-9.9) for rectal cancer. Low haemoglobin, high platelets and inflammatory markers increased from as early as 9 months pre-diagnosis. Conclusion: Our study found evidence for early increase in rates of consultation for relevant clinical features and abnormal blood tests in patients with colorectal cancer, suggesting that earlier instigation of cancer-specific investigations or referrals may be warranted in some symptomatic patients.
Collapse
|
11
|
Zhou Y, Walter FM, Mounce L, Abel GA, Singh H, Hamilton W, Stewart GD, Lyratzopoulos G. Identifying opportunities for timely diagnosis of bladder and renal cancer via abnormal blood tests: a longitudinal linked data study. Br J Gen Pract 2022; 72:e19-e25. [PMID: 34903517 PMCID: PMC8714503 DOI: 10.3399/bjgp.2021.0282] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 09/14/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Understanding pre-diagnostic test use could reveal diagnostic windows where more timely evaluation for cancer may be indicated. AIM To examine pre-diagnostic patterns of results of abnormal blood tests in patients with bladder and renal cancer. DESIGN AND SETTING A retrospective cohort study using primary care and cancer registry data on patients with bladder and renal cancer who were diagnosed between April 2012 and December 2015 in England. METHOD The rates of patients with a first abnormal result in the year before cancer diagnosis, for 'generic' (full blood count components, inflammatory markers, and calcium) and 'organ-specific' blood tests (creatinine and liver function test components) that may lead to subsequent detection of incidental cancers, were examined. Poisson regression was used to detect the month during which the cohort's rate of each abnormal test started to increase from baseline. The proportion of patients with a test found in the first half of the diagnostic window was examined, as these 'early' tests might represent opportunities where further evaluation could be initiated. RESULTS Data from 4533 patients with bladder and renal cancer were analysed. The monthly rate of patients with a first abnormal test increased towards the time of cancer diagnosis. Abnormalities of both generic (for example, high inflammatory markers) and organ-specific tests (for example, high creatinine) started to increase from 6-8 months pre-diagnosis, with 25%-40% of these patients having an abnormal test in the 'early half' of the diagnostic window. CONCLUSION Population-level signals of bladder and renal cancer can be observed in abnormalities in commonly performed primary care blood tests up to 8 months before diagnosis, indicating the potential for earlier diagnosis in some patients.
Collapse
Affiliation(s)
- Yin Zhou
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Fiona M Walter
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK; professor of primary care cancer research, Wolfson Institute of Population Health, Queen Mary University London, London, UK
| | - Luke Mounce
- University of Exeter Medical School, Exeter, UK
| | - Gary A Abel
- University of Exeter Medical School, Exeter, UK
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey Veterans Affairs Medical Center, Houston, TX, US; Baylor College of Medicine, Houston, TX, US
| | | | - Grant D Stewart
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Georgios Lyratzopoulos
- Epidemiology of Cancer Healthcare and Outcomes, Department of Behavioural Science and Health, Institute of Epidemiology and Health Care, University College London, London, UK
| |
Collapse
|
12
|
Harrison H, Usher-Smith JA, Li L, Roberts L, Lin Z, Thompson RE, Rossi SH, Stewart GD, Walter FM, Griffin S, Zhou Y. Risk prediction models for symptomatic patients with bladder and kidney cancer: a systematic review. Br J Gen Pract 2022; 72:e11-e18. [PMID: 34844922 PMCID: PMC8714528 DOI: 10.3399/bjgp.2021.0319] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 08/25/2021] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Timely diagnosis of bladder and kidney cancer is key to improving clinical outcomes. Given the challenges of early diagnosis, models incorporating clinical symptoms and signs may be helpful to primary care clinicians when triaging at-risk patients. AIM To identify and compare published models that use clinical signs and symptoms to predict the risk of undiagnosed prevalent bladder or kidney cancer. DESIGN AND SETTING Systematic review. METHOD A search identified primary research reporting or validating models predicting the risk of bladder or kidney cancer in MEDLINE and EMBASE. After screening identified studies for inclusion, data were extracted onto a standardised form. The risk models were classified using TRIPOD guidelines and evaluated using the PROBAST assessment tool. RESULTS The search identified 20 661 articles. Twenty studies (29 models) were identified through screening. All the models included haematuria (visible, non-visible, or unspecified), and seven included additional signs and symptoms (such as abdominal pain). The models combined clinical features with other factors (including demographic factors and urinary biomarkers) to predict the risk of undiagnosed prevalent cancer. Several models (n = 13) with good discrimination (area under the receiver operating curve >0.8) were identified; however, only eight had been externally validated. All of the studies had either high or unclear risk of bias. CONCLUSION Models were identified that could be used in primary care to guide referrals, with potential to identify lower-risk patients with visible haematuria and to stratify individuals who present with non-visible haematuria. However, before application in general practice, external validations in appropriate populations are required.
Collapse
Affiliation(s)
- Hannah Harrison
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge
| | - Juliet A Usher-Smith
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge
| | - Lanxin Li
- University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge
| | - Lydia Roberts
- University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge
| | - Zhiyuan Lin
- University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge
| | - Rachel E Thompson
- University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge
| | - Sabrina H Rossi
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge
| | - Grant D Stewart
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge
| | - Fiona M Walter
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, and director, Wolfson Institute of Population Health, Queen Mary University of London, London
| | - Simon Griffin
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge
| | - Yin Zhou
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge
| |
Collapse
|
13
|
Consultations for clinical features of possible cancer and associated urgent referrals before and during the COVID-19 pandemic: an observational cohort study from English primary care. Br J Cancer 2021; 126:948-956. [PMID: 34934176 PMCID: PMC8691390 DOI: 10.1038/s41416-021-01666-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 11/15/2021] [Accepted: 12/02/2021] [Indexed: 02/07/2023] Open
Abstract
Background It remains unclear to what extent reductions in urgent referrals for suspected cancer during the COVID-19 pandemic were the result of fewer patients attending primary care compared to GPs referring fewer patients. Methods Cohort study including electronic health records data from 8,192,069 patients from 663 English practices. Weekly consultation rates, cumulative consultations and referrals were calculated for 28 clinical features from the NICE suspected cancer guidelines. Clinical feature consultation rate ratios (CRR) and urgent referral rate ratios (RRR) compared time periods in 2020 with 2019. Findings Consultations for cancer clinical features decreased by 24.19% (95% CI: 24.04–24.34%) between 2019 and 2020, particularly in the 6–12 weeks following the first national lockdown. Urgent referrals for clinical features decreased by 10.47% (95% CI: 9.82–11.12%) between 2019 and 2020. Overall, once patients consulted with primary care, GPs urgently referred a similar or greater proportion of patients compared to previous years. Conclusion Due to the significant fall in patients consulting with clinical features of cancer there was a lower than expected number of urgent referrals in 2020. Sustained efforts should be made throughout the pandemic to encourage the public to consult their GP with cancer clinical features.
Collapse
|
14
|
Sun Z, Liu W, Zhang J, Wang S, Yang F, Fang Y, Jiang W, Ding L, Zhao H, Zhang Y. The Direct Semi-Quantitative Detection of 18 Pathogens and Simultaneous Screening for Nine Resistance Genes in Clinical Urine Samples by a High-Throughput Multiplex Genetic Detection System. Front Cell Infect Microbiol 2021; 11:660461. [PMID: 33912478 PMCID: PMC8072482 DOI: 10.3389/fcimb.2021.660461] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 03/22/2021] [Indexed: 01/26/2023] Open
Abstract
Background Urinary tract infections (UTIs) are one the most common infections. The rapid and accurate identification of uropathogens, and the determination of antimicrobial susceptibility, are essential aspects of the management of UTIs. However, existing detection methods are associated with certain limitations. In this study, a new urinary tract infection high-throughput multiplex genetic detection system (UTI-HMGS) was developed for the semi-quantitative detection of 18 pathogens and the simultaneously screening of nine resistance genes directly from the clinical urine sample within 4 hours. Methods We designed and optimized a multiplex polymerase chain reaction (PCR) involving fluorescent dye-labeled specific primers to detect 18 pathogens and nine resistance genes. The specificity of the UTI-HMGS was tested using standard strains or plasmids for each gene target. The sensitivity of the UTI-HMGS assay was tested by the detection of serial tenfold dilutions of plasmids or simulated positive urine samples. We also collected clinical urine samples and used these to perform urine culture and antimicrobial susceptibility testing (AST). Finally, all urine samples were detected by UTI-HMGS and the results were compared with both urine culture and Sanger sequencing. Results UTI-HMGS showed high levels of sensitivity and specificity for the detection of uropathogens when compared with culture and sequencing. In addition, ten species of bacteria and three species of fungi were detected semi-quantitatively to allow accurate discrimination of significant bacteriuria and candiduria. The sensitivity of the UTI-HMGS for the all the target genes could reach 50 copies per reaction. In total, 531 urine samples were collected and analyzed by UTI-HMGS, which exhibited high levels of sensitivity and specificity for the detection of uropathogens and resistance genes when compared with Sanger sequencing. The results from UTI-HMGS showed that the detection rates of 15 pathogens were significantly higher (P<0.05) than that of the culture method. In addition, there were 41(7.72%, 41/531) urine samples were positive for difficult-to-culture pathogens, which were missed detected by routine culture method. Conclusions UTI-HMGS proved to be an efficient method for the direct semi-quantitative detection of 18 uropathogens and the simultaneously screening of nine antibiotic resistance genes in urine samples. The UTI-HMGS could represent an alternative method for the clinical detection and monitoring of antibiotic resistance.
Collapse
Affiliation(s)
- Zhaoyang Sun
- Department of Laboratory Medicine, Huadong Hospital, Affiliated With Fudan University, Shanghai, China.,Key Laboratory of Clinical Geriatric Medicine, Shanghai, China.,Research Center on Aging and Medicine, Fudan University, Shanghai, China
| | - Wenjian Liu
- Department of Laboratory Medicine, Huadong Hospital, Affiliated With Fudan University, Shanghai, China.,Key Laboratory of Clinical Geriatric Medicine, Shanghai, China.,Research Center on Aging and Medicine, Fudan University, Shanghai, China
| | - Jinghao Zhang
- Department of Laboratory Medicine, Huadong Hospital, Affiliated With Fudan University, Shanghai, China.,Key Laboratory of Clinical Geriatric Medicine, Shanghai, China.,Research Center on Aging and Medicine, Fudan University, Shanghai, China
| | - Su Wang
- Department of Laboratory Medicine, Huadong Hospital, Affiliated With Fudan University, Shanghai, China.,Key Laboratory of Clinical Geriatric Medicine, Shanghai, China.,Research Center on Aging and Medicine, Fudan University, Shanghai, China
| | - Feng Yang
- Department of Laboratory Medicine, Huadong Hospital, Affiliated With Fudan University, Shanghai, China.,Key Laboratory of Clinical Geriatric Medicine, Shanghai, China.,Research Center on Aging and Medicine, Fudan University, Shanghai, China
| | - Yi Fang
- Department of Laboratory Medicine, Huadong Hospital, Affiliated With Fudan University, Shanghai, China.,Key Laboratory of Clinical Geriatric Medicine, Shanghai, China.,Research Center on Aging and Medicine, Fudan University, Shanghai, China
| | - Wenrong Jiang
- Department of Laboratory Medicine, Huadong Hospital, Affiliated With Fudan University, Shanghai, China.,Key Laboratory of Clinical Geriatric Medicine, Shanghai, China.,Research Center on Aging and Medicine, Fudan University, Shanghai, China
| | - Li Ding
- Department of Laboratory Medicine, Huadong Hospital, Affiliated With Fudan University, Shanghai, China.,Key Laboratory of Clinical Geriatric Medicine, Shanghai, China.,Research Center on Aging and Medicine, Fudan University, Shanghai, China
| | - Hu Zhao
- Department of Laboratory Medicine, Huadong Hospital, Affiliated With Fudan University, Shanghai, China.,Key Laboratory of Clinical Geriatric Medicine, Shanghai, China.,Research Center on Aging and Medicine, Fudan University, Shanghai, China
| | - Yanmei Zhang
- Department of Laboratory Medicine, Huadong Hospital, Affiliated With Fudan University, Shanghai, China.,Key Laboratory of Clinical Geriatric Medicine, Shanghai, China.,Research Center on Aging and Medicine, Fudan University, Shanghai, China
| |
Collapse
|