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Estupiñán Fdez de Mesa M, Marcu A, Ream E, Whitaker KL. Using the Candidacy Framework to understand individual, interpersonal, and system level factors driving inequities in women with breast cancer: a cross-sectional study. BJC REPORTS 2024; 2:83. [PMID: 39516542 PMCID: PMC11524000 DOI: 10.1038/s44276-024-00103-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 08/26/2024] [Accepted: 09/17/2024] [Indexed: 11/16/2024]
Abstract
BACKGROUND Persistent inequities in breast cancer outcomes exist. Understanding women's experiences along the care pathway is the first step to finding solutions to tackle these inequities. METHODS Secondary data analysis of the 2017/2018 English National Cancer Patient Experience Survey (n = 25,408) using logistic regression to explore inequities in care experience by sociodemographic factors (age, ethnicity, socioeconomic position, sexual orientation) across 59 survey questions. We used the Candidacy Framework to interpret and organise our findings. RESULTS Compared to older (65-74) and White British women, young (35-44, OR = 0.55 [0.44, 0.69]), Asian (OR = 0.52 [0.41, 0.67]), Black (OR = 0.67 [0.46, 0.97]) and White Other (OR = 0.63 [0.49, 0.81]) women were more likely to rate their overall care experience less positively, respectively. Similar findings were observed along all domains of the cancer pathway. Through a candidacy lens, we identified multilevel factors related to this variation including prolonged help-seeking behaviours (individual), poor patient-provider communication (interpersonal), and variation in access to healthcare professionals and resources (system level). CONCLUSION Multilevel factors influence inequities in the experience of care along the breast cancer pathway for young women and women from minoritised groups. Interventions are necessary to ensure cancer care systems are responsive to women's health needs and provide equity of care to all patients.
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Affiliation(s)
| | - Afrodita Marcu
- School of Health Sciences, University of Surrey, Research Park, Guildford, Surrey, GU2 7YH, UK
| | - Emma Ream
- School of Health Sciences, University of Surrey, Research Park, Guildford, Surrey, GU2 7YH, UK
| | - Katriina L Whitaker
- School of Health Sciences, University of Surrey, Research Park, Guildford, Surrey, GU2 7YH, UK
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2
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Hiscock J, Law RJ, Brain K, Smits S, Nafees S, Williams NH, Rose J, Lewis R, Roberts JL, Hendry A, Neal RD, Wilkinson C. Hidden systems in primary care cancer detection: an embedded qualitative intervention development study. Br J Gen Pract 2024; 74:e544-e551. [PMID: 38806209 PMCID: PMC11257065 DOI: 10.3399/bjgp.2023.0339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 05/13/2024] [Indexed: 05/30/2024] Open
Abstract
BACKGROUND UK cancer mortality is worse than in many other high-income countries, partly because of diagnostic delays in primary care. AIM To understand beliefs and behaviours of GPs, and systems of general practice teams, to inform the Think Cancer! intervention development. DESIGN AND SETTING An embedded qualitative study guided by behaviour change models (COM-B [Capability, Opportunity, Motivation - Behaviour] and theoretical domains framework [TDF]) in primary care in Wales, UK. METHOD Twenty qualitative, semi-structured telephone interviews with GPs were undertaken and four face-to-face focus groups held with practice teams. Framework analysis was used and results were mapped to multiple, overlapping components of COM-B and TDF. RESULTS Three themes illustrate complex, multilevel referral considerations facing GPs and practice teams; external influences and constraints; and the role of practice systems and culture. Tensions emerged between individual considerations of GPs (Capability and Motivation) and context-dependent external pressures (Opportunity). Detecting cancer was guided not only by external requirements, but also by motivational factors GPs described as part of their cancer diagnostics process. External influences on the diagnosis process often resulted from the primary-secondary care interface and social pressures. GPs adapted their behaviour to deal with this disconnect. Positive practice culture and supportive practice-based systems ameliorated these tensions and complexity. CONCLUSION By exploring individual GP behaviours together with practice systems and culture we contribute new understanding about how cancer diagnosis operates in primary care and how delays can be improved. We highlight commonly overlooked dynamics and tensions that are experienced by GPs as a tension between individual decision making (Capability and Motivation) and external considerations, such as pressures in secondary care (Opportunity).
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Affiliation(s)
- Julia Hiscock
- North Wales Centre for Primary Care Research (NWCPCR), Bangor University, Wrexham
| | - Rebecca-Jane Law
- North Wales Centre for Primary Care Research (NWCPCR), Bangor University, Wrexham
| | - Kate Brain
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff
| | - Stephanie Smits
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff
| | - Sadia Nafees
- North Wales Centre for Primary Care Research (NWCPCR), Bangor University, Wrexham
| | - Nefyn H Williams
- Department of Primary Care and Mental Health, Institute of Population Health, University of Liverpool, Liverpool
| | - Jan Rose
- North Wales Centre for Primary Care Research (NWCPCR), Bangor University, Wrexham
| | - Ruth Lewis
- North Wales Centre for Primary Care Research (NWCPCR), Bangor University, Wrexham
| | - Jessica L Roberts
- North Wales Centre for Primary Care Research (NWCPCR), Bangor University, Wrexham
| | - Annie Hendry
- North Wales Centre for Primary Care Research (NWCPCR), Bangor University, Wrexham
| | - Richard D Neal
- DISCO (Diagnosis of Symptomatic Cancer Optimally), University of Exeter, Exeter
| | - Clare Wilkinson
- North Wales Centre for Primary Care Research (NWCPCR), Bangor University, Wrexham
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Pearce H, Hamilton D, Sharp L, Deane J, Kennedy M, O'Hara J. Routes to diagnosis of hypopharyngeal cancer: A single-centre experience. Clin Otolaryngol 2024; 49:495-499. [PMID: 38515125 DOI: 10.1111/coa.14156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 02/07/2024] [Accepted: 03/10/2024] [Indexed: 03/23/2024]
Affiliation(s)
- Helen Pearce
- Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
| | - David Hamilton
- Department of Otolaryngology-Head and Neck Surgery, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
- Population Health Sciences Institute, Newcastle University, Newcastle-upon-Tyne, UK
| | - Linda Sharp
- Population Health Sciences Institute, Newcastle University, Newcastle-upon-Tyne, UK
| | - Jennifer Deane
- Population Health Sciences Institute, Newcastle University, Newcastle-upon-Tyne, UK
| | - Matthew Kennedy
- Department of Oral and Maxillofacial Surgery, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
| | - James O'Hara
- Department of Otolaryngology-Head and Neck Surgery, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
- Population Health Sciences Institute, Newcastle University, Newcastle-upon-Tyne, UK
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Hayes H, Meacock R, Stokes J, Sutton M. How do family doctors respond to reduced waiting times for cancer diagnosis in secondary care? THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2024; 25:813-828. [PMID: 37787842 PMCID: PMC11192671 DOI: 10.1007/s10198-023-01626-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 08/09/2023] [Indexed: 10/04/2023]
Abstract
Reducing waiting times is a priority in public health systems. Efforts of healthcare providers to shorten waiting times could be negated if they simultaneously induce substantial increases in demand. However, separating out the effects of changes in supply and demand on waiting times requires an exogenous change in one element. We examine the impact of a pilot programme in some English hospitals to shorten waiting times for urgent diagnosis of suspected cancer on family doctors' referrals. We examine referrals from 6,666 family doctor partnerships to 145 hospitals between 1st April 2012 and 31st March 2019. Five hospitals piloted shorter waiting times initiatives in 2017. Using continuous difference-in-differences regression, we exploit the pilot as a 'supply shifter' to estimate the effect of waiting times on referral volumes for two suspected cancer types: bowel and lung. The proportion of referred patients breaching two-week waiting times targets for suspected bowel cancer fell by 3.9 percentage points in pilot hospitals in response to the policy, from a baseline of 4.8%. Family doctors exposed to the pilot increased their referrals (demand) by 10.8%. However, the pilot was not successful for lung cancer, with some evidence that waiting times increased, and a corresponding reduction in referrals of -10.5%. Family doctor referrals for suspected cancer are responsive at the margin to waiting times. Healthcare providers may struggle to achieve long-term reductions in waiting times if supply-side improvements are offset by increases in demand.
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Affiliation(s)
- Helen Hayes
- Office of Health Economics (OHE), London, UK.
- Health Organisation, Policy and Economics (HOPE), Centre for Primary Care & Health Services Research, School of Health Sciences, The University of Manchester, Manchester, UK.
| | - Rachel Meacock
- Health Organisation, Policy and Economics (HOPE), Centre for Primary Care & Health Services Research, School of Health Sciences, The University of Manchester, Manchester, UK
| | - Jonathan Stokes
- Health Organisation, Policy and Economics (HOPE), Centre for Primary Care & Health Services Research, School of Health Sciences, The University of Manchester, Manchester, UK
- MRC/CSO Social & Public Health Sciences Unit, School of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Matt Sutton
- Health Organisation, Policy and Economics (HOPE), Centre for Primary Care & Health Services Research, School of Health Sciences, The University of Manchester, Manchester, UK
- Melbourne Institute of Applied Economic and Social Research, Faculty of Business and Economics, The University of Melbourne, Parkville, VIC, Australia
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5
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Holdroyd I, Chadwick W, Harvey-Sullivan A, Bartholomew T, Massou E, Tzortziou Brown V, Ford J. Single-handed versus multiple-handed general practices: A cross-sectional study of quality outcomes in England. J Health Serv Res Policy 2024; 29:201-209. [PMID: 38091626 PMCID: PMC11151703 DOI: 10.1177/13558196231218830] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
OBJECTIVES As general practice increasingly moves towards large group practices, there is debate about the relative benefits, safety and sustainability of different care delivery models. This study investigates the performance of single-handed practices compared to practices with multiple doctors in England, UK. METHODS Practices in England with more than 1000 patients were included. Workforce data and a quality control process classified practices as single-handed or multiple-handed. Outcomes were (i) GP patient survey scores measuring access, continuity, confidence in health professional and overall satisfaction; (ii) reported diabetes and hypertension outcomes; and (iii) emergency department presentation rates and cancer detection (percentage of cancers diagnosed by a 2-week wait). Generalised linear models, controlling for patient and practice characteristics, compared outcomes in single and multiple-handed practices and assessed the effect of GP age in single-handed practices. RESULTS Single-handed practices were more commonly found in areas of high deprivation (41% compared to 20% of multiple-handed practices). Single-handed practices had higher patient-reported access, continuity and overall satisfaction but slightly lower diabetes management and cancer detection rates. Emergency department presentations were higher when controlling for patient characteristics in single-handed practices but not when also controlling for practice rurality and size. Increased deprivation was associated with lower performance in seven out of eight outcomes. CONCLUSIONS We found single-handed practices to be associated with high patient satisfaction while performing slightly less well on selected clinical outcomes. Further research is required to better understand the association between practice size, including increasing multidisciplinary working, on patient experience and outcomes.
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Affiliation(s)
- Ian Holdroyd
- Foundation Doctor, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - William Chadwick
- Foundation Doctor, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Adam Harvey-Sullivan
- Academic Clinical Fellow, Wolfson Institute for Population Health, Queen Mary University of London, London, UK
| | - Theodore Bartholomew
- GP Registrar, General Practice, Royal Surrey NHS Foundation Trust, Guildford, UK
| | - Efthalia Massou
- Research Associate, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Victoria Tzortziou Brown
- Senior Clinical Lecturer, Wolfson Institute for Population Health, Queen Mary University of London, London, UK
| | - John Ford
- Senior Clinical Lecturer in Health Equity, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
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6
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Hayes H, Meacock R, Stokes J, Sutton M. The effect of local hospital waiting times on GP referrals for suspected cancer. PLoS One 2024; 19:e0294061. [PMID: 38718085 PMCID: PMC11078401 DOI: 10.1371/journal.pone.0294061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 10/24/2023] [Indexed: 05/12/2024] Open
Abstract
INTRODUCTION Reducing waiting times is a major policy objective in publicly-funded healthcare systems. However, reductions in waiting times can produce a demand response, which may offset increases in capacity. Early detection and diagnosis of cancer is a policy focus in many OECD countries, but prolonged waiting periods for specialist confirmation of diagnosis could impede this goal. We examine whether urgent GP referrals for suspected cancer patients are responsive to local hospital waiting times. METHOD We used annual counts of referrals from all 6,667 general practices to all 185 hospital Trusts in England between April 2012 and March 2018. Using a practice-level measure of local hospital waiting times based on breaches of the two-week maximum waiting time target, we examined the relationship between waiting times and urgent GP referrals for suspected cancer. To identify whether the relationship is driven by differences between practices or changes over time, we estimated three regression models: pooled linear regression, a between-practice estimator, and a within-practice estimator. RESULTS Ten percent higher rates of patients breaching the two-week wait target in local hospitals were associated with higher volumes of referrals in the pooled linear model (4.4%; CI 2.4% to 6.4%) and the between-practice estimator (12.0%; CI 5.5% to 18.5%). The relationship was not statistically significant using the within-practice estimator (1.0%; CI -0.4% to 2.5%). CONCLUSION The positive association between local hospital waiting times and GP demand for specialist diagnosis was caused by practices with higher levels of referrals facing longer local waiting times. Temporal changes in waiting times faced by individual practices were not related to changes in their referral volumes. GP referrals for diagnostic cancer services were not found to respond to waiting times in the short-term. In this setting, it may therefore be possible to reduce waiting times by increasing supply without consequently increasing demand.
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Affiliation(s)
- Helen Hayes
- Office of Health Economics (OHE), London, United Kingdom
- Health Organisation, Policy and Economics (HOPE), Centre for Primary Care & Health Services Research, School of Health Sciences, The University of Manchester, Manchester, United Kingdom
| | - Rachel Meacock
- Health Organisation, Policy and Economics (HOPE), Centre for Primary Care & Health Services Research, School of Health Sciences, The University of Manchester, Manchester, United Kingdom
| | - Jonathan Stokes
- Health Organisation, Policy and Economics (HOPE), Centre for Primary Care & Health Services Research, School of Health Sciences, The University of Manchester, Manchester, United Kingdom
- MRC/CSO Social & Public Health Sciences Unit, School of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Matt Sutton
- Health Organisation, Policy and Economics (HOPE), Centre for Primary Care & Health Services Research, School of Health Sciences, The University of Manchester, Manchester, United Kingdom
- Centre for Health Economics, Monash University, Melbourne, Victoria, Australia
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7
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Round T, Sethuraman L, Ashworth M, Purushotham A. Transforming post pandemic cancer services. Br J Cancer 2024; 130:1233-1238. [PMID: 38491174 PMCID: PMC11014976 DOI: 10.1038/s41416-024-02596-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 11/15/2023] [Accepted: 01/19/2024] [Indexed: 03/18/2024] Open
Abstract
This paper outlines the impact of the COVID-19 pandemic on cancer services in the UK including screening, symptomatic diagnosis, treatment pathways and projections on clinical outcomes as a result of these care disruptions. A restoration of cancer services to pre-pandemic levels is not likely to mitigate this adverse impact, particularly with an ageing population and increased cancer burden. New cancer cases are projected to rise to over 500,000 per year by 2035, with over 4 million people living with and beyond cancer. This paper calls for a strategic transformation to prioritise effort on the basis of available datasets and evidence-in particular, to prioritise cancers where an earlier diagnosis is feasible and clinically useful with a focus on mortality benefit by preventing emergency presentations by harnessing data and analytics. This could be delivered by a focus on underperforming groups/areas to try and reduce inequity, linking near real-time datasets with clinical decision support systems at the primary and secondary care levels, promoting the use of novel technologies to improve patient uptake of services, screening and diagnosis, and finally, upskilling and cross-skilling healthcare workers to expand supply of diagnostic and screening services.
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Affiliation(s)
- Thomas Round
- School of Life Course and Population Sciences, King's College London, London, UK.
| | | | - Mark Ashworth
- School of Life Course and Population Sciences, King's College London, London, UK
| | - Arnie Purushotham
- School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
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Kovacevic L, Naik R, Lugo-Palacios DG, Ashrafian H, Mossialos E, Darzi A. The impact of collaborative organisational models and general practice size on patient safety and quality of care in the English National Health Service: A systematic review. Health Policy 2023; 138:104940. [PMID: 37976620 DOI: 10.1016/j.healthpol.2023.104940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 10/31/2023] [Accepted: 11/03/2023] [Indexed: 11/19/2023]
Abstract
Collaborative primary care has become an increasingly popular strategy to manage existing pressures on general practice. In England, the recent changes taking place in the primary care sector have included the formation of collaborative organisational models and a steady increase in practice size. The aim of this review was to summarise the available evidence on the impact of collaborative models and general practice size on patient safety and quality of care in England. We searched for quantitative and qualitative studies on the topic published between January 2010 and July 2023. The quality of articles was assessed using the Newcastle-Ottawa Scale and the Critical Appraisal Skills Programme checklist. We screened 6533 abstracts, with full-text screening performed on 76 records. A total of 29 articles were included in the review. 19 met the inclusion criteria following full-text screening, with seven identified through reverse citation searching and three through expert consultation. All studies were found to be of moderate or high quality. A predominantly positive impact on service delivery measures and patient-level outcomes was identified. Meanwhile, the evidence on the effect on pay-for-performance outcomes and hospital admissions is mixed, with continuity of care and access identified as a concern. While this review is limited to evidence from England, the findings provide insights for all health systems undergoing a transition towards collaborative primary care.
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Affiliation(s)
- Lana Kovacevic
- NIHR Imperial Patient Safety Translational Research Centre, Institute of Global Health Innovation, Imperial College London, Queen Elizabeth Queen Mother Wing, St Mary's Hospital, South Wharf Road, W2 1NY, London, UK; Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, W2 1NY, London, UK.
| | - Ravi Naik
- Institute of Global Health Innovation, Imperial College London, Faculty Building, South Kensington Campus, Kensington, SW7 2AZ, London, UK; Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, W2 1NY, London, UK
| | - David G Lugo-Palacios
- Institute of Global Health Innovation, Imperial College London, Faculty Building, South Kensington Campus, Kensington, SW7 2AZ, London, UK; Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, WC1H 9SH, London, UK
| | - Hutan Ashrafian
- Institute of Global Health Innovation, Imperial College London, Faculty Building, South Kensington Campus, Kensington, SW7 2AZ, London, UK; Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, W2 1NY, London, UK
| | - Elias Mossialos
- Institute of Global Health Innovation, Imperial College London, Faculty Building, South Kensington Campus, Kensington, SW7 2AZ, London, UK; Department of Health Policy, London School of Economics and Political Science, Houghton Street, WC2A 2AE, London, UK
| | - Ara Darzi
- Institute of Global Health Innovation, Imperial College London, Faculty Building, South Kensington Campus, Kensington, SW7 2AZ, London, UK; Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, W2 1NY, London, UK
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Conroy S, Catto JWF, Bex A, Brown JE, Cartledge J, Fielding A, Jones RJ, Khoo V, Nicol D, Stewart GD, Sullivan M, Tran MGB, Woodward R, Cumberbatch MG. Diagnosis, treatment, and survival from kidney cancer: real-world National Health Service England data between 2013 and 2019. BJU Int 2023; 132:541-553. [PMID: 37436368 DOI: 10.1111/bju.16128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2023]
Abstract
OBJECTIVES To report the NHS Digital (NHSD) data for patients diagnosed with kidney cancer (KC) in England. We explore the incidence, route to diagnosis (RTD), treatment, and survival patterns from 2013 to 2019. MATERIALS AND METHODS Data was extracted from the Cancer Data NHSD portal for International Classification of Diseases, 10th edition coded KC; this included Cancer Registry data, Hospital Episode Statistics, and cancer waiting times data. RESULTS Registrations included 66 696 individuals with KC. Incidence of new KC diagnoses increased (8998 in 2013, to 10 232 in 2019), but the age-standardised rates were stable (18.7-19.4/100 000 population). Almost half of patients (30 340 [45.5%]) were aged 0-70 years and the cohort were most frequently diagnosed with Stage 1-2 KC (n = 26 297 [39.4%]). Most patients were diagnosed through non-urgent general practitioner referrals (n = 16 814 [30.4%]), followed by 2-week-wait (n = 15 472 [28.0%]) and emergency routes (n = 11 796 [21.3%]), with older patients (aged ≥70 years), Stage 4 KCs, and patients with non-specified renal cell carcinoma being significantly more likely to present through the emergency route (all P < 0.001). Invasive treatment (surgery or ablation), radiotherapy, or systemic anti-cancer therapy use varied with disease stage, patient factors, and treatment network (Cancer Alliance). Survival outcomes differed by Stage, histological subtype, and social deprivation class (P < 0.001). Age-standardised mortality rates did not change over the study duration, although immunotherapy usage is likely not captured in this study timeline. CONCLUSION The NHSD resource provides useful insight about the incidence, diagnostic pathways, treatment, and survival of patients with KC in England and a useful benchmark for the upcoming commissioned National Kidney Cancer Audit. The RTD data may be limited by incidental diagnoses, which could confound the high proportion of 'emergency' diagnoses. Importantly, survival outcomes remained relatively unchanged.
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Affiliation(s)
- Samantha Conroy
- Sheffield Teaching Hospitals Foundation Trust, Sheffield, UK
- Academic Unit of Urology, Department of Oncology and Metabolism, University of Sheffield Medical School, Sheffield, UK
| | - James W F Catto
- Sheffield Teaching Hospitals Foundation Trust, Sheffield, UK
- Academic Unit of Urology, Department of Oncology and Metabolism, University of Sheffield Medical School, Sheffield, UK
| | - Axel Bex
- Royal Free NHS Foundation Trust, Specialist Centre for Kidney Cancer, London, UK
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Janet E Brown
- Sheffield Teaching Hospitals Foundation Trust, Sheffield, UK
- Academic Unit of Clinical Oncology, Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | | | - Alison Fielding
- Bladder and Renal Cancer Clinical Studies Group, National Cancer Research Institute, London, UK
| | - Rob J Jones
- Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Vincent Khoo
- Royal Marsden NHS Foundation Trust, London, UK
- Institute of Cancer Research, London, UK
| | - David Nicol
- Royal Marsden NHS Foundation Trust, London, UK
- Institute of Cancer Research, London, UK
| | - Grant D Stewart
- Department of Surgery, University of Cambridge, Cambridge, UK
| | - Mark Sullivan
- Department of Urology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- University of Oxford, Oxford, UK
| | - Maxine G B Tran
- Royal Free NHS Foundation Trust, Specialist Centre for Kidney Cancer, London, UK
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Rose Woodward
- Action Kidney Cancer, Manchester, UK
- International Kidney Cancer Coalition, UK
| | - Marcus G Cumberbatch
- Sheffield Teaching Hospitals Foundation Trust, Sheffield, UK
- Academic Unit of Urology, Department of Oncology and Metabolism, University of Sheffield Medical School, Sheffield, UK
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10
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Scott SE, Gildea C, Nicholson BD, Evans RE, Waller J, Smith D, Purushotham A, Round T. Future cancer risk after urgent suspected cancer referral in England when cancer is not found: a national cohort study. Lancet Oncol 2023; 24:1242-1251. [PMID: 37922929 DOI: 10.1016/s1470-2045(23)00435-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 08/16/2023] [Accepted: 08/17/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Following referral for investigation of urgent suspected cancer within the English National Health Service referral system, 7% of referred individuals are diagnosed with cancer. This study aimed to investigate the risk of cancer occurrence within 1-5 years of finding no cancer following an urgent suspected cancer referral. METHODS This national cohort study used urgent suspected cancer referral data for England from the Cancer Waiting Times dataset and linked it with cancer diagnosis data from the National Cancer Registration dataset. Data were extracted for the eight most commonly referred to urgent suspected cancer referral pathways (breast, gynaecological, head and neck, lower and upper gastrointestinal, lung, skin, and urological) for the period April 1, 2013, to March 31, 2014, with 5-year follow-up for individuals with no cancer diagnosis within 1 year of referral. The primary objective was to investigate the occurrence and type of subsequent cancer in years 1-5 following an urgent suspected cancer referral when no cancer was initially found, both overall and for each of the eight referral pathways. The numbers of subsequent cancers were compared with expected cancer incidence in years 1-5 following referral, using standardised incidence ratios (SIRs) based on matched age-gender distributions of expected cancer incidence in England for the same time period. The analysis was repeated, stratifying by referral group, and by calculating the absolute and expected rate of all cancers and of the same individual cancer as the initial referral. FINDINGS Among 1·18 million referrals without a cancer diagnosis in years 0-1, there were 63 112 subsequent cancers diagnosed 1-5 years post-referral, giving an absolute rate of 1338 (95% CI 1327-1348) cancers per 100 000 referrals per year (1038 [1027-1050] in females, 1888 [1867-1909] in males), compared with an expected rate of 1054 (1045-1064) cancers per 100 000 referrals per year (SIR 1·27 [95% CI 1·26-1·28]). The absolute rate of any subsequent cancer diagnosis 1-5 years after referral was lowest following suspected breast cancer referral (746 [728-763] cancers per 100 000 referrals per year) and highest following suspected urological (2110 [2070-2150]) or lung cancer (1835 [1767-1906]) referral. For diagnosis of the same cancer as the initial referral pathway, the highest absolute rates were for the urological and lung pathways (1011 [984-1039] and 638 [598-680] cancers per 100 000 referrals per year, respectively). The highest relative risks of subsequent diagnosis of the same cancer as the initial referral pathway were for the head and neck pathway (SIR 3·49 [95% CI 3·22-3·78]) and lung pathway (3·00 [2·82-3·20]). INTERPRETATION Cancer risk was higher than expected in the 5 years following an urgent suspected cancer referral. The potential for targeted interventions, such as proactive monitoring, safety-netting, and cancer awareness or risk reduction initiatives should be investigated. FUNDING Cancer Research UK.
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Affiliation(s)
- Suzanne E Scott
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK; King's College London, London, UK.
| | | | - Brian D Nicholson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ruth E Evans
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | | | | | | | - Thomas Round
- King's College London, London, UK; National Disease Registration Service, NHS England, UK
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11
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Swann R, McPhail S, Abel GA, Witt J, Wills L, Hiom S, Lyratzopoulos G, Rubin G. National Cancer Diagnosis Audits for England 2018 versus 2014: a comparative analysis. Br J Gen Pract 2023; 73:e566-e574. [PMID: 37253630 PMCID: PMC10242853 DOI: 10.3399/bjgp.2022.0268] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 08/28/2022] [Accepted: 01/18/2023] [Indexed: 03/17/2023] Open
Abstract
BACKGROUND Timely diagnosis of cancer in patients who present with symptoms in primary care is a quality-improvement priority. AIM To examine possible changes to aspects of the diagnostic process, and its timeliness, before and after publication of the National Institute for Health and Care Excellence's (2015) guidance on the referral of suspected cancer in primary care. DESIGN AND SETTING Comparison of findings from population-based clinical audits of cancer diagnosis in general practices in England for patients diagnosed in 2018 or 2014. METHOD GPs in 1878 (2018) and 439 (2014) practices collected primary care information on the diagnostic pathway of cancer patients. Key measures including patient characteristics, place of presentation, number of pre-referral consultations, use of primary care investigations, and referral type were compared between the two audits by descriptive analysis and regression models. RESULTS Among 64 489 (2018) and 17 042 (2014) records of a new cancer diagnosis, the percentage of patients with same-day referral (denoted by a primary care interval of 0 days) was higher in 2018 (42.7% versus 37.7%) than in 2014, with similar improvements in median diagnostic interval (36 days versus 40 days). Compared with 2014, in 2018: fewer patients had ≥3 pre-referral consultations (18.8% versus 26.2%); use of primary care investigations increased (47.9% versus 45.4%); urgent cancer referrals increased (54.8% versus 51.8%); emergency referrals decreased (13.4% versus 16.5%); and recorded use of safety netting decreased (40.0% versus 44.4%). CONCLUSION In the 5-year period, including the year when national guidelines were updated (that is, 2015), there were substantial improvements to the diagnostic process of patients who present to general practice in England with symptoms of a subsequently diagnosed cancer.
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Affiliation(s)
| | - Sean McPhail
- National Cancer Registration and Analysis Service, NHS Digital, Leeds
| | - Gary A Abel
- University of Exeter Medical School (Primary Care), University of Exeter, Exeter
| | - Jana Witt
- Cystic Fibrosis Trust, London; former NCDA programme manager, Cancer Research UK, London
| | | | - Sara Hiom
- NHS Implementation & External Affairs; former director, Cancer Intelligence, Early Diagnosis and Clinical Engagement, Cancer Research UK, London
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Evans REC, Waller J, Nicholson BD, Round T, Gildea C, Smith D, Scott SE. Should we? Could we? Feasibility of interventions to support prevention or early diagnosis of future cancer following urgent referral: A qualitative study. PATIENT EDUCATION AND COUNSELING 2023; 112:107757. [PMID: 37099888 DOI: 10.1016/j.pec.2023.107757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 03/30/2023] [Accepted: 04/14/2023] [Indexed: 05/09/2023]
Abstract
OBJECTIVE This study investigated perspectives of healthcare professionals (HCPs) on the feasibility of giving additional support to patients after cancer is not found following urgent referral. We sought to understand key facilitators or barriers to offering such support. METHODS A convenience sample of primary and secondary care healthcare professionals (n = 36) participated in semi-structured interviews. Interviews were transcribed verbatim and analysed using Framework Analysis, inductively and deductively, guided by the Theoretical Domains Framework. RESULTS HCPs indicated that support should be offered if proven to be efficacious. It needs to avoid potential negative consequences such as patient anxiety and information overload. HCPs were more hesitant about whether support could feasibly be offered, due to resource restrictions and perceived remit of the urgent pathway for suspected cancer. CONCLUSION HCP support after discharge from urgent cancer referral pathways needs to be resource efficient, developed in collaboration with patients and should have proven efficacy. Development of brief interventions for delivery by a range of staff, and use of technology could mitigate barriers to implementation. PRACTICE IMPLICATIONS Changes to discharge procedures to provide information, endorsement or direction to services could offer much needed support. Additional support would need to overcome logistical challenges and address limited capacity.
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Affiliation(s)
| | | | - Brian D Nicholson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
| | | | | | | | - Suzanne E Scott
- King's College London, UK; Queen Mary University of London, UK.
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Bradley SH. Increases in GP cancer referrals reflect successful health policy, not accidental overmedicalisation. BMJ 2023; 381:p1349. [PMID: 37339813 DOI: 10.1136/bmj.p1349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
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Mathew R. Rammya Mathew: Are we a cancer service or a health service? BMJ 2023; 381:1382. [PMID: 37339801 DOI: 10.1136/bmj.p1382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
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Almalki H, Rankin AC, Juette A, Youssef MG. Radio-frequency identification (RFID) tag localisation of non-palpable breast lesions a single centre experience. Breast 2023; 69:417-421. [PMID: 37141675 PMCID: PMC10300563 DOI: 10.1016/j.breast.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 04/18/2023] [Accepted: 04/22/2023] [Indexed: 05/06/2023] Open
Abstract
AIM The purpose of this study is to report the surgical experience and outcomes with pre-operative localisation of non-palpable breast lesions using the RFID tag system. METHODS The cohort for this prospective study included patients over the age of 18 with biopsy proven, non-palpable indeterminate lesions, DCIS or breast cancer requiring pre-operative localisation before surgical excision between September 2020 and July 2022. RESULTS A total of 312 RFID tags were placed in 299 consecutive patients. Indications for localisation included non-palpable invasive cancer in 255 (85.3%) patients, in situ disease in 38 (12.7%) and indeterminate lesions requiring surgical excision in 6 (2.0%). Both in situ and invasive lesions had a median size of 13 mm (range 4-100 mm) on pre-operative imaging. The RFID tags were in situ for a median time of 21 days before surgery (range 0-233 days). Of the 213 tags, 292 (93.6%) were introduced using ultrasound (USS) guidance and stereotactically in 20 (6.4%). In 3 (1.0%) cases the RFID tag was either not satisfactorily deployed at the intended target or retrieved intra-operatively. Following discussion of post-operative histology by the multi-disciplinary team, further surgery for close or involved margins was for 26 (8.7%) patients. CONCLUSION The Hologic RFID tag system can be used for accurate pre-operative localisation of non-palpable masses as well as diffuse abnormalities such as mammographic distortions and calcifications. It has advantages of flexibility for scheduling image-guided insertion independently of scheduled operating lists and can be placed to localise lesions prior to initiating neoadjuvant systemic treatment.
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Affiliation(s)
- Hend Almalki
- Department of Breast Surgery, Norfolk and Norwich University Hospital, UK
| | - Adeline C Rankin
- Department of Breast Surgery, Norfolk and Norwich University Hospital, UK
| | - Arne Juette
- Department of Breast Imaging, Norfolk and Norwich University Hospital, UK
| | - MinaM G Youssef
- Department of Breast Surgery, Norfolk and Norwich University Hospital, UK.
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Merriel SWD, Francetic I, Buttle P. Direct access to imaging for cancer from primary care. BMJ 2023; 380:e074766. [PMID: 36758979 DOI: 10.1136/bmj-2023-074766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Affiliation(s)
- Samuel W D Merriel
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester, UK
| | - Igor Francetic
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester, UK
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Trends and variation in urgent referrals for suspected cancer 2009/2010-2019/2020. Br J Gen Pract 2022; 72:34-37. [PMID: 34972804 PMCID: PMC8714520 DOI: 10.3399/bjgp22x718217] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
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Round T, Ashworth M. The Interface Between Colon Cancer and Mental Health Morbidities. JAMA Netw Open 2022; 5:e2238579. [PMID: 36315155 DOI: 10.1001/jamanetworkopen.2022.38579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Thomas Round
- School of Life Course and Population Sciences, King's College London, London, United Kingdom
| | - Mark Ashworth
- School of Life Course and Population Sciences, King's College London, London, United Kingdom
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Associations between general practice characteristics and chest X-ray rate: an observational study. Br J Gen Pract 2021; 72:e34-e42. [PMID: 34903518 PMCID: PMC8714512 DOI: 10.3399/bjgp.2021.0232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 08/10/2021] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Chest X-ray (CXR) is the first-line test for lung cancer in many settings. Previous research has suggested that higher utilisation of CXR is associated with improved outcomes. AIM To explore the associations between characteristics of general practices and frequency of investigation with CXR. DESIGN AND SETTING Retrospective observational study of English general practices. METHOD A database was constructed of English general practices containing number of CXRs requested and data on practices for 2018, including patient and staff demographics, smoking prevalence, deprivation, and patient satisfaction indicators. Mixed-effects Poisson modelling was used to account for variation because of chance and to estimate the amount of remaining variation that could be attributed to practice and population characteristics. RESULTS There was substantial variation in GP CXR rates (median 34 per 1000 patients, interquartile range 26-43). Only 18% of between-practice variance in CXR rate was accounted for by recorded characteristics. Higher practice scores for continuity and communication skills, and higher proportions of smokers, Asian and mixed ethnic groups, and patients aged >65 years were associated with increased CXR rates. Higher patient satisfaction scores for access and greater proportions of male patients and patients of Black ethnicity were associated with lower CXR rates. CONCLUSION Substantial variation was found in CXR rates beyond that expected by chance, which could not be accounted for by practices' recorded characteristics. As other research has indicated that increasing CXR rates can lead to earlier detection, supporting practices that currently investigate infrequently could be an effective strategy to improve lung cancer outcomes.
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Keenan R, Lawrenson R, Stokes T. Urgent referral to specialist services for patients with cancer symptoms: a cause for concern or oversimplifying a complex issue? BMJ Qual Saf 2021; 31:558-560. [PMID: 34862314 DOI: 10.1136/bmjqs-2021-014222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Rawiri Keenan
- Medical Research Centre, University of Waikato, Hamilton, New Zealand
| | - Ross Lawrenson
- Medical Research Centre, University of Waikato, Hamilton, New Zealand
| | - Tim Stokes
- Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
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Urgent cancer referrals: how well are they working and can they be improved? Br J Gen Pract 2021; 71:390-391. [PMID: 34446404 DOI: 10.3399/bjgp21x716801] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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