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Suryani ND, Wiranata JA, Puspitaningtyas H, Hutajulu SH, Prabandari YS, Handaya AY, Hardianti MS, Taroeno-Hariadi KW, Kurnianda J, Purwanto I. Determining factors of presentation and diagnosis delays in patients with colorectal cancer and the impact on stage: a cross sectional study in Yogyakarta, Indonesia. Ecancermedicalscience 2024; 18:1761. [PMID: 39430075 PMCID: PMC11489102 DOI: 10.3332/ecancer.2024.1761] [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: 03/13/2024] [Indexed: 10/22/2024] Open
Abstract
Background Early colorectal cancer (CRC) symptom recognition and prompt diagnosis are crucial for the identification of cases in the earliest stage and for improving survival. This study investigates the incidence of presentation and diagnosis delays, their contributing determinants and their impact on the cancer stage at diagnosis. Methods This cross-sectional study recruited 227 CRC patients between November 2022 and October 2023. We developed a semi-structured questionnaire to collect information on the factors related to delays in the presentation and diagnosis. Presentation delay was defined as the time between the initial symptoms and the first consultation exceeding 1 month, while diagnosis delay was defined as the time between presentation and the pathological diagnosis confirmation exceeding 4 months. We examined the impact of these delays on the status of the metastatic disease and identified the determinants of the presentation and diagnosis delays. Results The median values for presentation and diagnosis delay are 1 and 4 months, respectively. Patients aged ≥60 years were less likely to experience diagnosis delays odds ratio (OR = 0.52, 95% confidence interval (CI) 0.28-0.95, p = 0.035), as opposed to those who were younger. The absence of red flag symptoms at presentation (OR = 2.73, 95% CI 1.47-5.10, p = 0.002), the utilisation of complementary and alternative medicine (OR = 2.01, 95% CI 1.12-3.61, p = 0.019) and ≥3 distinct healthcare facility visits before diagnosis (OR = 3.51, 95% CI 1.95-6.29, p < 0.001) were associated with an increased risk of diagnosis delays. Diagnosis delays were also correlated with a higher risk of metastatic disease at diagnosis (OR = 2.04, 95% CI 1.17-3.53, p = 0.011). Conclusion Our CRC patients experience considerable delays in their presentation and diagnosis. Diagnosis delays were observed to increase the likelihood of presenting with metastatic disease. Given the determinants and the patients' perspectives revealed in this study, future research to explore evidence-based approaches to reducing these delays is warranted.
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Affiliation(s)
- Norma Dewi Suryani
- Clinical Epidemiology Study Program, Master of Clinical Medicine Postgraduate Program, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta 55281, Indonesia
| | - Juan Adrian Wiranata
- Clinical Epidemiology Study Program, Master of Clinical Medicine Postgraduate Program, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta 55281, Indonesia
- Academic Hospital, Universitas Gadjah Mada, Yogyakarta 55281, Indonesia
| | - Herindita Puspitaningtyas
- Doctorate Program of Health and Medical Science, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta 55281, Indonesia
| | - Susanna Hilda Hutajulu
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Dr. Sardjito General Hospital, Yogyakarta 55281, Indonesia
| | - Yayi Suryo Prabandari
- Department of Health Behaviour, Environment, and Social Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta 55281, Indonesia
- Center of Health Behaviour and Promotion, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta 55281, Indonesia
| | - Adeodatus Yuda Handaya
- Department of Surgery, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta 55281, Indonesia
| | - Mardiah Suci Hardianti
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Dr. Sardjito General Hospital, Yogyakarta 55281, Indonesia
| | - Kartika Widayati Taroeno-Hariadi
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Dr. Sardjito General Hospital, Yogyakarta 55281, Indonesia
| | - Johan Kurnianda
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Dr. Sardjito General Hospital, Yogyakarta 55281, Indonesia
| | - Ibnu Purwanto
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Dr. Sardjito General Hospital, Yogyakarta 55281, Indonesia
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Rafiq M, Drosdowsky A, Solomon B, Alexander M, Gibbs P, Wright G, Yeung JM, Lyratzopoulos G, Emery J. Trends in primary care blood tests prior to lung and colorectal cancer diagnosis-A retrospective cohort study using linked Australian data. Cancer Med 2024; 13:e70006. [PMID: 39001673 PMCID: PMC11245636 DOI: 10.1002/cam4.70006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 06/20/2024] [Accepted: 06/30/2024] [Indexed: 07/16/2024] Open
Abstract
INTRODUCTION Abnormal results in common blood tests may occur several months before lung cancer (LC) and colorectal cancer (CRC) diagnosis. Identifying early blood markers of cancer and distinct blood test signatures could support earlier diagnosis in general practice. METHODS Using linked Australian primary care and hospital cancer registry data, we conducted a cohort study of 855 LC and 399 CRC patients diagnosed between 2001 and 2021. Requests and results from general practice blood tests (six acute phase reactants [APR] and six red blood cell indices [RBCI]) were examined in the 2 years before cancer diagnosis. Poisson regression models were used to estimate monthly incidence rates and examine pre-diagnostic trends in blood test use and abnormal results prior to cancer diagnosis, comparing patterns in LC and CRC patients. RESULTS General practice blood test requests increase from 7 months before CRC and 6 months before LC diagnosis. Abnormalities in many APR and RBCI tests increase several months before cancer diagnosis, often occur prior to or in the absence of anaemia (in 51% of CRC and 81% of LC patients with abnormalities), and are different in LC and CRC patients. CONCLUSIONS This study demonstrates an increase in diagnostic activity in Australian general practice several months before LC and CRC diagnosis, indicating potential opportunities for earlier diagnosis. It identifies blood test abnormalities and distinct signatures that are early markers of LC and CRC. If combined with other pre-diagnostic information, these blood tests have potential to support GPs in prioritising patients for cancer investigation of different sites to expedite diagnosis.
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Affiliation(s)
- Meena Rafiq
- Department of General Practice and Centre for Cancer Research, University of Melbourne, Melbourne, Victoria, Australia
- Epidemiology of Cancer Healthcare & Outcomes (ECHO) Group, Department of Behavioural Science and Health, Institute of Epidemiology and Health Care (IECH), UCL, London, UK
| | - Allison Drosdowsky
- Department of General Practice and Centre for Cancer Research, University of Melbourne, Melbourne, Victoria, Australia
| | - Ben Solomon
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | | | - Peter Gibbs
- Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia
| | - Gavin Wright
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Justin M Yeung
- Department of Surgery, Western Precinct, University of Melbourne, Melbourne, Victoria, Australia
| | - Georgios Lyratzopoulos
- Epidemiology of Cancer Healthcare & Outcomes (ECHO) Group, Department of Behavioural Science and Health, Institute of Epidemiology and Health Care (IECH), UCL, London, UK
| | - Jon Emery
- Department of General Practice and Centre for Cancer Research, University of Melbourne, Melbourne, Victoria, Australia
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Wickramasinghe B, Renzi C, Barclay M, Callister MEJ, Rafiq M, Lyratzopoulos G. Pre-diagnostic prescribing patterns in dyspnoea patients with as-yet-undiagnosed lung cancer: A longitudinal study of linked primary care and cancer registry data. Cancer Epidemiol 2023; 86:102429. [PMID: 37473578 DOI: 10.1016/j.canep.2023.102429] [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: 03/29/2023] [Revised: 07/10/2023] [Accepted: 07/13/2023] [Indexed: 07/22/2023]
Abstract
INTRODUCTION Patients with as-yet undiagnosed lung cancer (LC) can present to primary care with non-specific symptoms such as dyspnoea, often in the context of pre-existing chronic obstructive pulmonary disease (COPD). Related medication prescriptions pre-diagnosis might represent opportunities for earlier diagnosis, but UK evidence is limited. Consequently, we explored prescribing patterns of relevant medications in patients who presented with dyspnoea in primary care and were subsequently diagnosed with LC. METHOD Linked primary care (Clinical Practice Research Datalink) and National Cancer Registry data were used to identify 5434 patients with incident LC within a year of a dyspnoea presentation in primary care between 2006 and 2016. Primary care prescriptions relevant to dyspnoea management were examined: antibiotics, inhaled medications, oral steroids, and opioid analgesics. Poisson regression models estimated monthly prescribing rates during the year pre-diagnosis. Variation by COPD status (52 % pre-existing, 36 % COPD-free, 12 % new-onset) was examined. Inflection points were identified indicating when prescribing rates changed from the background rate. RESULTS 63 % of patients received 1 or more relevant prescriptions 1-12 months pre-diagnosis. Pre-existing COPD patients were most prescribed inhaled medications. COPD-free and new-onset COPD patients were most prescribed antibiotics. Most patients received 2 or more relevant prescriptions. Monthly prescribing rates of all medications increased towards time of diagnosis in all patient groups and were highest in pre-existing COPD patients. Increases in prescribing activity were observed earliest in pre-existing COPD patients 5 months pre-diagnosis for inhaled medications, antibiotics, and steroids, CONCLUSION: Results indicate that a diagnostic window of appreciable length exists for potential earlier LC diagnosis in some patients. Lung cancer diagnosis may be delayed if early symptoms are misattributed to COPD or other benign conditions.
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Affiliation(s)
- Bethany Wickramasinghe
- Epidemiology of Cancer Healthcare & Outcomes (ECHO) Group, Dept. of Behavioural Science & Health, Institute of Epidemiology and Health Care (IEHC), University College London, United Kingdom.
| | - Cristina Renzi
- Epidemiology of Cancer Healthcare & Outcomes (ECHO) Group, Dept. of Behavioural Science & Health, Institute of Epidemiology and Health Care (IEHC), University College London, United Kingdom
| | - Matthew Barclay
- Epidemiology of Cancer Healthcare & Outcomes (ECHO) Group, Dept. of Behavioural Science & Health, Institute of Epidemiology and Health Care (IEHC), University College London, United Kingdom
| | - Matthew E J Callister
- Department of Respiratory Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Meena Rafiq
- Epidemiology of Cancer Healthcare & Outcomes (ECHO) Group, Dept. of Behavioural Science & Health, Institute of Epidemiology and Health Care (IEHC), University College London, United Kingdom
| | - Georgios Lyratzopoulos
- Epidemiology of Cancer Healthcare & Outcomes (ECHO) Group, Dept. of Behavioural Science & Health, Institute of Epidemiology and Health Care (IEHC), University College London, United Kingdom
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Hermiö E, Seppä K, Ryynänen H, Hirvonen E, Pylkkänen L, Järvelin J, Malila N, Pitkäniemi J. Use of health services one year before primary colorectal cancer. BMC Health Serv Res 2023; 23:279. [PMID: 36959641 PMCID: PMC10035279 DOI: 10.1186/s12913-023-09298-7] [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: 05/16/2022] [Accepted: 03/16/2023] [Indexed: 03/25/2023] Open
Abstract
BACKGROUND Colorectal cancer (CRC) patient pathways focus typically on periods after confirmed diagnosis and only limited data are available on pathways prior to cancer diagnosis. The aim of the study was to describe the use of health services (HS) one year before diagnosis among CRC patients in Finland. We also studied the role of sex, age, stage, and university hospital district in relation to the use of HS during the pre-diagnostic phase. This information is expected to bring light on the question why CRC is often not found in its early stages. METHODS Incident CRC cases (N = 3115) concerning year 2015 were retrieved from the Finnish Cancer Registry and linked with data from the Finnish Institute for Health and Welfare on primary or specialised care outpatient visits or inpatient episodes over one year prior to CRC diagnosis. We modelled the average number of HS events per patient using Poisson regression model with log-link. Change points for monthly HS event rates and 95% CIs one year before diagnosis were evaluated using Poisson broken line regression models. RESULTS Around 10% of patients diagnosed in 2015 had no events prior to cancer leaving 2816 CRCs in the study. Of all pre-diagnostic events (N = 23268), 86% were outpatient events and 14% inpatient episodes. More than half of the inpatient episodes (65%) started as urgent admissions. The use of HS started to increase 3-4 months before diagnosis. The average number of pre-diagnostic HS events per patient varied by sex, age, stage and university hospital district. Overall, men had more events per patient than women and older patients had more events than younger patients. CONCLUSIONS The amount of inpatient episodes starting as urgent admissions indicate potential bottlenecks in the access to health services. An increase in service use only 3-4 months prior to diagnosis reflects a need for advice both for health care professionals and the general population in recognising symptoms of CRC.
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Affiliation(s)
- Elina Hermiö
- Unit of Health Sciences, Faculty of Social Sciences, Tampere University, Tampere, 33014, Finland.
- Cancer Society of Finland, Unioninkatu 22, 00130, Helsinki, Finland.
| | - Karri Seppä
- Cancer Society of Finland, Unioninkatu 22, 00130, Helsinki, Finland
| | - Heidi Ryynänen
- Cancer Society of Finland, Unioninkatu 22, 00130, Helsinki, Finland
| | - Elli Hirvonen
- Cancer Society of Finland, Unioninkatu 22, 00130, Helsinki, Finland
| | | | - Jutta Järvelin
- Finnish Institute for Health and Welfare, PL 30, 00271, Helsinki, Finland
| | - Nea Malila
- Cancer Society of Finland, Unioninkatu 22, 00130, Helsinki, Finland
| | - Janne Pitkäniemi
- Unit of Health Sciences, Faculty of Social Sciences, Tampere University, Tampere, 33014, Finland
- Cancer Society of Finland, Unioninkatu 22, 00130, Helsinki, Finland
- University of Helsinki, Yliopistonkatu 4, 00100, Helsinki, Finland
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Benitez Majano S, Lyratzopoulos G, de Wit NJ, White B, Rachet B, Helsper C, Usher-Smith J, Renzi C. Mental Health Morbidities and Time to Cancer Diagnosis Among Adults With Colon Cancer in England. JAMA Netw Open 2022; 5:e2238569. [PMID: 36315146 PMCID: PMC9623442 DOI: 10.1001/jamanetworkopen.2022.38569] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 08/29/2022] [Indexed: 11/29/2022] Open
Abstract
Importance Mental health morbidity (MHM) in patients presenting with possible cancer symptoms may be associated with prediagnostic care and time to cancer diagnosis. Objective To compare the length of intervals to cancer diagnosis by preexisting MHM status in patients who presented with symptoms of as-yet-undiagnosed colon cancer and evaluate their risk of emergency cancer diagnosis. Design, Setting, and Participants This cohort study was conducted using linked primary care data obtained from the population-based Clinical Practice Research Datalink, which includes primary care practices in England, linked to cancer registry and hospital data. Included participants were 3766 patients diagnosed with colon cancer between 2011 and 2015 presenting with cancer-relevant symptoms up to 24 months before their diagnosis. Data analysis was performed in January 2021 to April 2022. Exposures Mental health conditions recorded in primary care before cancer diagnosis, including anxiety, depression, schizophrenia, bipolar disorder, alcohol addiction, anorexia, and bulimia. Main Outcomes and Measures Fast-track (also termed 2-week wait) specialist referral for investigations, time to colonoscopy and cancer diagnosis, and risk of emergency cancer diagnosis. Results Among 3766 patients with colon cancer (median [IQR] age, 75 [65-82] years; 1911 [50.7%] women ), 623 patients [16.5%] had preexisting MHM recorded in primary care the year before cancer diagnosis, including 562 patients (14.9%) with preexisting anxiety or depression (accounting for 90.2% of patients with preexisting MHM) and 61 patients (1.6%) with other MHM; 3143 patients (83.5%) did not have MHM. Patients with MHM had records of red-flag symptoms or signs (ie, rectal bleeding, change in bowel habit, or anemia) in the 24 months before cancer diagnosis in a smaller proportion compared with patients without MHM (308 patients [49.4%] vs 1807 patients [57.5%]; P < .001). Even when red-flag symptoms were recorded, patients with MHM had lower odds of fast-track specialist referral (adjusted odds ratio [OR] = 0.72; 95% CI, 0.55-0.94; P = .01). Among 2115 patients with red-flag symptoms or signs, 308 patients with MHM experienced a more than 2-fold longer median (IQR) time to cancer diagnosis (326 [75-552] days vs 133 [47-422] days) and higher odds of emergency diagnosis (90 patients [29.2%] vs 327 patients [18.1%]; adjusted OR = 1.63; 95% CI, 1.23-2.24; P < .001) compared with 1807 patients without MHM. Conclusions and Relevance This study found that patients with MHM experienced large and prognostically consequential disparities in diagnostic care before a colon cancer diagnosis. These findings suggest that appropriate pathways and follow-up strategies after symptomatic presentation are needed for earlier cancer diagnoses and improved health outcomes in this large patient group.
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Affiliation(s)
- Sara Benitez Majano
- Inequalities in Cancer Outcomes Network Group, Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Georgios Lyratzopoulos
- Epidemiology of Cancer Healthcare and Outcomes Research Group, Department of Behavioural Science and Health, Institute of Epidemiology and Health Care, University College London, London, United Kingdom
| | - Niek J. de Wit
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht University, Utrecht, the Netherlands
| | - Becky White
- Epidemiology of Cancer Healthcare and Outcomes Research Group, Department of Behavioural Science and Health, Institute of Epidemiology and Health Care, University College London, London, United Kingdom
| | - Bernard Rachet
- Inequalities in Cancer Outcomes Network Group, Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Charles Helsper
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht University, Utrecht, the Netherlands
| | - Juliet Usher-Smith
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Cristina Renzi
- Epidemiology of Cancer Healthcare and Outcomes Research Group, Department of Behavioural Science and Health, Institute of Epidemiology and Health Care, University College London, London, United Kingdom
- Faculty of Medicine, University Vita-Salute San Raffaele, Milan, Italy
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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.
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Boakye D, Günther K, Niedermaier T, Haug U, Ahrens W, Nagrani R. Associations between comorbidities and advanced stage diagnosis of lung, breast, colorectal, and prostate cancer: A systematic review and meta-analysis. Cancer Epidemiol 2021; 75:102054. [PMID: 34773768 DOI: 10.1016/j.canep.2021.102054] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 09/30/2021] [Accepted: 10/20/2021] [Indexed: 12/20/2022]
Abstract
Comorbidities and advanced stage diagnosis (ASD) are both associated with poorer cancer outcomes, but the association between comorbidities and ASD is poorly understood. We summarized epidemiological evidence on the association between comorbidities and ASD of selected cancers in a systematic review and meta-analysis. We searched PubMed and Web of Science databases up to June 3rd, 2021 for studies assessing the association between comorbidities and ASD of lung, breast, colorectal, or prostate cancer. Summary odds ratios (ORs) and 95% confidence intervals (95%CIs) were calculated using random-effects models. Also, potential variations in the associations between comorbidities and ASD by cancer type were investigated using random-effects meta-regression. Thirty-seven studies were included in this review, including 8,069,397 lung, breast, colorectal, and prostate cancer patients overall. The Charlson comorbidity index score was positively associated with ASD (stages III-IV) of breast cancer but was inversely associated with ASD of lung cancer (pinteraction = 0.004). Regarding specific comorbidities, diabetes was positively associated with ASD (OR = 1.17, 95%CI = 1.09-1.26), whereas myocardial infarction was inversely associated with ASD (OR = 0.84, 95%CI = 0.75-0.95). The association between renal disease and ASD differed by cancer type (pinteraction < 0.001). A positive association was found with prostate cancer (OR = 2.02, 95%CI = 1.58-2.59) and an inverse association with colorectal cancer (OR = 0.84, 95%CI = 0.70-1.00). In summary, certain comorbidities (e.g., diabetes) may be positively associated with ASD of several cancer types. It needs to be clarified whether closer monitoring for early cancer signs or screening in these patients is reasonable, considering the problem of over-diagnosis particularly relevant in patients with short remaining life expectancy such as those with comorbidities. Also, evaluation of the cost-benefit relationship of cancer screening according to the type and severity of comorbidity (rather than summary scores) may be beneficial for personalized cancer screening in populations with chronic diseases.
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Affiliation(s)
- Daniel Boakye
- Department of Epidemiological Methods and Etiological Research, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany.
| | - Kathrin Günther
- Department of Epidemiological Methods and Etiological Research, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany
| | - Tobias Niedermaier
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Ulrike Haug
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany; Faculty of Human and Health Sciences, University of Bremen, Bremen, Germany
| | - Wolfgang Ahrens
- Department of Epidemiological Methods and Etiological Research, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany; Institute of Statistics, Faculty of Mathematics and Computer Science, University of Bremen, Bremen, Germany
| | - Rajini Nagrani
- Department of Epidemiological Methods and Etiological Research, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany
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Cubiella J, Lorenzo M, Baiocchi F, Tejido C, Conde A, Sande-Meijide M, Castro M. Impact of a colorectal cancer screening program implantation on delays and prognosis of non-screening detected colorectal cancer. World J Gastroenterol 2021; 27:6689-6700. [PMID: 34754161 PMCID: PMC8554396 DOI: 10.3748/wjg.v27.i39.6689] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 07/15/2021] [Accepted: 09/08/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The implementation of a colorectal cancer (CRC) screening programme may increase the awareness of Primary Care Physicians, reduce the diagnostic delay in CRC detected outside the scope of the screening programme and thus improve prognosis.
AIM To determine the effect of implementation of a CRC screening programme on diagnostic delays and prognosis of CRC detected outside the scope of a screening programme.
METHODS We performed a retrospective intervention study with a pre-post design. We identified 322 patients with incident and confirmed CRC in the pre-implantation cohort (June 2014 – May 2015) and 285 in the post-implantation cohort (June 2017 - May 2018) in the Cancer Registry detected outside the scope of a CRC screening programme. In each patient we calculated the different healthcare diagnostics delays: global, primary and secondary healthcare, referral and colonoscopy-related delays. In addition, we collected the initial healthcare that evaluated the patient, the home location (urban/rural), and the CRC stage at diagnosis. We determined the two-year survival and we performed a multivariate proportional hazard regression analysis to determine the variables associated with survival.
RESULTS We did not detect any differences in the patient or CRC baseline-related variables. A total of 20.1% of patients was detected with metastatic disease. There was a significant increase in direct referral to colonoscopy from primary healthcare (25.5%, 35.8%; P = 0.04) in the post-implantation cohort. Diagnostic delay was reduced by 24 d (106.64 ± 148.84 days, 82.84 ± 109.31 d; P = 0.02) due to the reduction in secondary healthcare delay (46.01 ± 111.65 d; 29.20 ± 60.83 d; P = 0.02). However, we did not find any differences in CRC stage at diagnosis or in two-year survival (70.3%; P = 0.9). Variables independently associated with two-year risk of death were age (Hazard Ratio-HR: 1.06, 95%CI: 1.04-1.07), CRC stage (II HR: 2.17, 95%CI: 1.07-4.40; III HR: 3.07, 95%CI: 1.56-6.08; IV HR: 19.22, 95%CI: 9.86-37.44; unknown HR: 9.24, 95%CI: 4.27-19.99), initial healthcare consultation (secondary HR: 2.93, 95%CI: 1.01-8.55; emergency department HR: 2.06, 95%CI: 0.67-6.34), hospitalization during the diagnostic process (HR: 1.67, 95%CI: 1.17-2.38) and urban residence (HR: 1.44, 95%CI: 1.06-1.98).
CONCLUSION Although implementation of a CRC screening programme can reduce diagnostic delays for CRC detected in symptomatic patients, this has no effect on CRC stage or survival.
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Affiliation(s)
- Joaquin Cubiella
- Department of Gastroenterology, Complexo Hospitalario Universitario de Ourense, Ourense 32005, Orense, Spain
| | - María Lorenzo
- Department of Preventive Medicine, Complexo Hospitalario Universitario de Ourense, Ourense 32003, Orense, Spain
| | - Franco Baiocchi
- Department of Gastroenterology, Hospital del Bierzo, Ponferrada 24404, Leon, Spain
| | - Coral Tejido
- Department of Gastroenterology, Complexo Hospitalario Universitario de Ourense, Ourense 32005, Orense, Spain
| | - Alejandro Conde
- Department of Preventive Medicine, Complexo Hospitalario Universitario de Ourense, Ourense 32003, Orense, Spain
| | - María Sande-Meijide
- Department of Preventive Medicine, Complexo Hospitalario Universitario de Ourense, Ourense 32003, Orense, Spain
| | - Margarita Castro
- Dirección Xeral de Saúde Pública, Conselleria de Sanidade, Santiago de Compostela 15703, Spain
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Ahmed RN, Rai L, Samo KA, Saeed S, Salam A, Khan H, Memon AS. Factors affecting delay in diagnosis of colorectal cancer: A cross-sectional study from a tertiary care hospital of Karachi, Pakistan. Int J Clin Pract 2021; 75:e14529. [PMID: 34128572 DOI: 10.1111/ijcp.14529] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 06/13/2021] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Colorectal cancer (CRC) incidence is increasing in our region. There is no specific CRC control programme or national cancer registry in Pakistan. Previously, no data have been published on presentation delay and diagnosis delay of CRC in our region. This study is conducted to determine the factors affecting delay in presentation and diagnosis and to provide baseline information to launch a CRC control programme. The primary objective is to determine factors causing delay in diagnosis of CRC. The secondary objective is to evaluate the relationship between tumour site and stage of CRC with presenting symptoms and symptom duration. METHODS This project is a prospective cross-sectional study on 113 biopsy-proven CRC patients admitted to the surgical ward of Civil Hospital Karachi. RESULTS The total number of participants was 113. Presentation delay was observed in 83.2% of patients. The main reasons for a reported delay in the presentation were lack of patients' knowledge that these symptoms may be cancer (60.4%), the wrong diagnosis by the primary physician (34.6%) or the patient did not want to visit the doctor (0.04%). Most tumours (95%) originated from the sigmoid and rectum; 44.2% and 38.9% of the patients were diagnosed at Stages 3 and 4, respectively. CONCLUSIONS This study revealed that CRC patients in Pakistan are facing delays in presentation and diagnosis. This is the reason behind diagnosis at the advanced stage with a poor prognosis. On the basis of this study findings, CRC control programme should be introduced to detect CRC at an early stage.
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Affiliation(s)
- Rubab Nafees Ahmed
- Surgical Unit 3, Dr. Ruth K.M Pfau Civil Hospital, Dow University of Health Sciences, Karachi, Pakistan
| | - Lajpat Rai
- Surgical Unit 3, Dr. Ruth K.M Pfau Civil Hospital, Dow University of Health Sciences, Karachi, Pakistan
| | - Khursheed Ahmed Samo
- Surgical Unit 3, Dr. Ruth K.M Pfau Civil Hospital, Dow University of Health Sciences, Karachi, Pakistan
| | - Summaya Saeed
- Surgical Unit 3, Dr. Ruth K.M Pfau Civil Hospital, Dow University of Health Sciences, Karachi, Pakistan
| | - Ammara Salam
- Department Surgery, PAF Faisal Hospital, Fazaia Ruth Pfau Medical College, Karachi, Pakistan
| | - Hina Khan
- Surgical Unit 3, Dr. Ruth K.M Pfau Civil Hospital, Dow University of Health Sciences, Karachi, Pakistan
| | - Amjad Siraj Memon
- Surgical Unit 3, Dr. Ruth K.M Pfau Civil Hospital, Dow University of Health Sciences, Karachi, Pakistan
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10
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Kuiper JG, van Herk-Sukel MPP, Lemmens VEPP, Kuipers EJ, Herings RMC. A steep increase in healthcare seeking behaviour in the last months before colorectal cancer diagnosis. BMC FAMILY PRACTICE 2021; 22:121. [PMID: 34154545 PMCID: PMC8218384 DOI: 10.1186/s12875-021-01482-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 05/20/2021] [Indexed: 12/22/2022]
Abstract
Background Timely recognition of colorectal cancer related symptoms is essential to reduce time to diagnosis. This study aims to investigate the primary healthcare use preceding a colorectal cancer diagnosis. Methods From a cohort of linked cancer and primary care data, patients diagnosed with primary colorectal cancer in the period 2007–2014 were selected and matched to cancer-free controls on gender, birth year, GP practice and follow-up period. Primary healthcare use among colorectal cancer cases before diagnosis was compared with matched cancer-free controls. Mean monthly number of GP consultations and newly prescribed medication was assessed in the year before index date (diagnosis date for cases). Results were stratified by colorectal cancer site: proximal colon cancer, distal colon cancer and rectal cancer. Results A total of 6,087 colorectal cancer cases could be matched to four cancer-free controls (N = 24,348). While mean monthly number of GP consultation were stable through the year among cancer-free controls, a statistical significant increase was seen among colorectal cancer cases in the last 4–8 months before diagnosis. Proximal colon cancer cases showed the longest time interval of increased mean monthly number of GP consultations. This increase was largely driven by a consultation for malignant neoplasm colon/rectum. The number patients receiving a newly prescribed medication was stable around 120 per 1,000 persons per month until 8 months before index date for proximal colon cancer cases, 4 months before index date for distal colon cancer cases and 3 months for rectal cancer cases. This increase was mainly driven by the prescription of laxatives drugs. Conclusion An increase in the healthcare seeking behaviour of colorectal cancer patients prior to diagnosis was seen. The longest period of increased GP consultations and newly prescribed medication was seen among patients diagnosed with proximal colon cancer. This can be explained by the difficultly to diagnose proximal colon cancer given the more subtle signs compared to distal colon cancer and rectal cancer. Therefore, faster diagnosis for this specific tumour subtype may only be possible when clear clinical signs and symptoms are present.
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Affiliation(s)
- Josephina G Kuiper
- PHARMO Institute for Drug Outcomes Research, Van Deventerlaan 30-40, 3528 AE, Utrecht, Netherlands. .,Department of Public Health, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, Netherlands.
| | - Myrthe P P van Herk-Sukel
- Department of Internal Medicine and Dermatology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, Netherlands
| | - Valery E P P Lemmens
- Department of Public Health, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, Netherlands.,Netherlands Comprehensive Cancer Organisation (IKNL), Godebaldkwartier 419, 3511 DT, Utrecht, Netherlands
| | - Ernst J Kuipers
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, Netherlands
| | - Ron M C Herings
- PHARMO Institute for Drug Outcomes Research, Van Deventerlaan 30-40, 3528 AE, Utrecht, Netherlands.,Department of Epidemiology & Data Science, Amsterdam University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, Netherlands
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11
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Webber C, Whitehead M, Eisen A, Holloway CMB, Groome PA. Factors associated with waiting time to breast cancer diagnosis among symptomatic breast cancer patients: a population-based study from Ontario, Canada. Breast Cancer Res Treat 2021; 187:225-235. [PMID: 33486544 DOI: 10.1007/s10549-020-06051-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 12/07/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE A prolonged time from first presentation to cancer diagnosis has been associated with worse disease-related outcomes. This study evaluated potential determinants of a long diagnostic interval among symptomatic breast cancer patients. METHODS This was a population-based, cross-sectional study of symptomatic breast cancer patients diagnosed in Ontario, Canada from 2007 to 2015 using administrative health data. The diagnostic interval was defined as the time from the earliest breast cancer-related healthcare encounter before diagnosis to the diagnosis date. Potential determinants of the diagnostic interval included patient, disease and usual healthcare utilization characteristics. We used multivariable quantile regression to evaluate their relationship with the diagnostic interval. We also examined differences in diagnostic interval by the frequency of encounters within the interval. RESULTS Among 45,967 symptomatic breast cancer patients, the median diagnostic interval was 41 days (interquartile range 20-92). Longer diagnostic intervals were observed in younger patients, patients with higher burden of comorbid disease, recent immigrants to Canada, and patients with higher healthcare utilization prior to their diagnostic interval. Shorter intervals were observed in patients residing in long-term care facilities, patients with late stage disease, and patients who initially presented in an emergency department. Longer diagnostic intervals were characterized by an increased number of physician visits and breast procedures. CONCLUSIONS The identification of groups at risk of longer diagnostic intervals provides direction for future research aimed at better understanding and improving breast cancer diagnostic pathways. Ensuring that all women receive a timely breast cancer diagnosis could improve breast cancer outcomes.
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Affiliation(s)
- Colleen Webber
- Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Queen's University, Kingston, ON, Canada
| | | | - Andrea Eisen
- Cancer Care Ontario, Toronto, ON, Canada.,University of Toronto, Toronto, ON, Canada
| | - Claire M B Holloway
- Cancer Care Ontario, Toronto, ON, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Patti A Groome
- Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Queen's University, Kingston, ON, Canada. .,ICES Queen's, Kingston, ON, Canada. .,Department of Public Health Sciences, Queen's University, Kingston, ON, Canada.
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12
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Renzi C, Kaushal A, Emery J, Hamilton W, Neal RD, Rachet B, Rubin G, Singh H, Walter FM, de Wit NJ, Lyratzopoulos G. Comorbid chronic diseases and cancer diagnosis: disease-specific effects and underlying mechanisms. Nat Rev Clin Oncol 2019; 16:746-761. [PMID: 31350467 DOI: 10.1038/s41571-019-0249-6] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2019] [Indexed: 02/06/2023]
Abstract
An earlier diagnosis is a key strategy for improving the outcomes of patients with cancer. However, achieving this goal can be challenging, particularly for the growing number of people with one or more chronic conditions (comorbidity/multimorbidity) at the time of diagnosis. Pre-existing chronic diseases might affect patient participation in cancer screening, help-seeking for new and/or changing symptoms and clinicians' decision-making on the use of diagnostic investigations. Evidence suggests, for example, that pre-existing pulmonary, cardiovascular, neurological and psychiatric conditions are all associated with a more advanced stage of cancer at diagnosis. By contrast, hypertension and certain gastrointestinal and musculoskeletal conditions might be associated with a more timely diagnosis. In this Review, we propose a comprehensive framework that encompasses the effects of disease-specific, patient-related and health-care-related factors on the diagnosis of cancer in individuals with pre-existing chronic illnesses. Several previously postulated aetiological mechanisms (including alternative explanations, competing demands and surveillance effects) are integrated with newly identified mechanisms, such as false reassurances, or patient concerns about appearing to be a hypochondriac. By considering specific effects of chronic diseases on diagnostic processes and outcomes, tailored early diagnosis initiatives can be developed to improve the outcomes of the large proportion of patients with cancer who have pre-existing chronic conditions.
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Affiliation(s)
- Cristina Renzi
- ECHO (Epidemiology of Cancer Healthcare and Outcomes) Research Group, Department of Behavioural Science and Health, Institute of Epidemiology & Health Care, University College London, London, UK.
- Cancer Survival Group, Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK.
| | - Aradhna Kaushal
- ECHO (Epidemiology of Cancer Healthcare and Outcomes) Research Group, Department of Behavioural Science and Health, Institute of Epidemiology & Health Care, University College London, London, UK
| | - Jon Emery
- Centre for Cancer Research and Department of General Practice, University of Melbourne, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia
| | - Willie Hamilton
- St Luke's Campus, University of Exeter Medical School, Exeter, UK
| | - Richard D Neal
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Bernard Rachet
- Cancer Survival Group, Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Greg Rubin
- Institute of Health and Society, Sir James Spence Institute, Newcastle University, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, TX, USA
| | - Fiona M Walter
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Niek J de Wit
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht University, Utrecht, Netherlands
| | - Georgios Lyratzopoulos
- ECHO (Epidemiology of Cancer Healthcare and Outcomes) Research Group, Department of Behavioural Science and Health, Institute of Epidemiology & Health Care, University College London, London, UK
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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13
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van Erp NF, Helsper CW, Olyhoek SM, Janssen RRT, Winsveen A, Peeters PHM, de Wit NJ. Potential for Reducing Time to Referral for Colorectal Cancer Patients in Primary Care. Ann Fam Med 2019; 17:419-427. [PMID: 31501203 PMCID: PMC7032917 DOI: 10.1370/afm.2446] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 03/29/2019] [Accepted: 04/11/2019] [Indexed: 12/15/2022] Open
Abstract
PURPOSE An optimal diagnostic process in primary care is pivotal for reducing cancer-related disease burden. This study aims to explore reasons for long times to referral for Dutch colorectal cancer (CRC) patients in primary care. METHODS A retrospective cohort study of anonymized free-text primary care records from the Julius General Practitioners' Network database, linked to the Netherlands Cancer Registry. Patients with a confirmed CRC diagnosis from 2007 through 2011 that symptomatically presented in primary care were included. Median time and interquartile ranges from presentation in primary care to referral were calculated for multiple patient and presentation characteristics. Associations of these characteristics with long time to referral (75th percentile was ≥59 days) were examined with log-binomial regression analyses. Routes to referral of patients with the longest times to referral were explored using thematic free-text analyses (90th percentile at ≥219 days). RESULTS Among the 309 people with CRC, patients who were female, did not have a registered family history, had a history of malignancy, lacked alarm symptoms at presentation, or had hemorrhoids at physical examination were at risk for longer time to referral in univariable analyses (longer median durations and/or univariable association with the 75th percentile). Only presentation without alarm symptoms showed a statistically significant association with long duration (75th percentile) in multivariable analysis (relative risk = 1.7; 95% CI, 1.1-2.6). Thematic exploration of the diagnostic routes to referral of patients with the longest durations (90th percentile) showed 2 dominating themes: "alternative working diagnosis" and "suboptimal diagnostic strategies," and included the sub-themes "omitting to reconsider an initial diagnosis" and "lacking follow-up." CONCLUSIONS Long time to referral for CRC in primary care is mainly related to low cancer suspicion. There is potential for reducing the longest times to referral for patients with CRC in primary care, with earlier reconsideration of the initial hypothesis and implementation of strict follow-up consultations.
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Affiliation(s)
- Nicole F van Erp
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Charles W Helsper
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Saskia M Olyhoek
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Ramon R T Janssen
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Amber Winsveen
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Petra H M Peeters
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Niek J de Wit
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
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14
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Renzi C, Lyratzopoulos G, Hamilton W, Maringe C, Rachet B. Contrasting effects of comorbidities on emergency colon cancer diagnosis: a longitudinal data-linkage study in England. BMC Health Serv Res 2019; 19:311. [PMID: 31092238 PMCID: PMC6521448 DOI: 10.1186/s12913-019-4075-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 04/08/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND One in three colon cancers are diagnosed as an emergency, which is associated with worse cancer outcomes. Chronic conditions (comorbidities) affect large proportions of adults and they might influence the risk of emergency presentations (EP). METHODS We aimed to evaluate the effect of specific pre-existing comorbidities on the risk of colon cancer being diagnosed following an EP rather than through non-emergency routes. The cohort study included 5745 colon cancer patients diagnosed in England 2005-2010, with individually-linked cancer registry, primary and secondary care data. In addition to multivariable analyses we also used potential-outcomes methods. RESULTS Colon cancer patients with comorbidities consulted their GP more frequently with cancer symptoms during the pre-diagnostic year, compared with non-comorbid cancer patients. EP occurred more frequently in patients with 'serious' or complex comorbidities (diabetes, cardiac and respiratory diseases) diagnosed/treated in hospital during the years pre-cancer diagnosis (43% EP in comorbid versus 27% in non-comorbid individuals; multivariable analysis Odds Ratio (OR), controlling for socio-demographic factors and symptoms: men OR = 2.40; 95% CI 2.0-2.9 and women OR = 1.98; 95% CI 1.6-2.4. Among women younger than 60, gynaecological (OR = 3.41; 95% CI 1.2-9.9) or recent onset gastro-intestinal conditions (OR = 2.84; 95% CI 1.1-7.7) increased the risk of EP. In contrast, primary care visits for hypertension monitoring decreased EPs for both genders. CONCLUSIONS Patients with comorbidities have a greater risk of being diagnosed with cancer as an emergency, although they consult more frequently with cancer symptoms during the year pre-cancer diagnosis. This suggests that comorbidities may interfere with diagnostic reasoning or investigations due to 'competing demands' or because they provide 'alternative explanations'. In contrast, the management of chronic risk factors such as hypertension may offer opportunities for earlier diagnosis. Interventions are needed to support the diagnostic process in comorbid patients. Appropriate guidelines and diagnostic services to support the evaluation of new or changing symptoms in comorbid patients may be useful.
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Affiliation(s)
- Cristina Renzi
- Department of Behavioural Science and Health, ECHO (Epidemiology of Cancer Healthcare & Outcomes) Research Group, University College London, 1-19 Torrington Place, London, WC1E 6BT UK
- Department of Non-communicable Disease Epidemiology, Cancer Survival Group, London School of Hygiene and Tropical Medicine, Keppel St, Bloomsbury, London, WC1E 7HT UK
| | - Georgios Lyratzopoulos
- Department of Behavioural Science and Health, ECHO (Epidemiology of Cancer Healthcare & Outcomes) Research Group, University College London, 1-19 Torrington Place, London, WC1E 6BT UK
| | - Willie Hamilton
- University of Exeter Medical School, St Luke’s Campus, Heavitree Road, Exeter, EX1 2LU UK
| | - Camille Maringe
- Department of Non-communicable Disease Epidemiology, Cancer Survival Group, London School of Hygiene and Tropical Medicine, Keppel St, Bloomsbury, London, WC1E 7HT UK
| | - Bernard Rachet
- Department of Non-communicable Disease Epidemiology, Cancer Survival Group, London School of Hygiene and Tropical Medicine, Keppel St, Bloomsbury, London, WC1E 7HT UK
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15
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Ewing M, Naredi P, Zhang C, Månsson J. Diagnostic profile characteristics of cancer patients with frequent consultations in primary care before diagnosis: a case-control study. Fam Pract 2018; 35:559-566. [PMID: 29546418 DOI: 10.1093/fampra/cmy012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Many patients with common cancers are late diagnosed. OBJECTIVES Identify consultation profiles and clinical features in patients with the seven most common cancers, who had consulted a general practitioner (GP) frequently before their cancer diagnosis. METHODS A case-control study was conducted in Region Västra Götaland, Sweden. A total of 2570 patients, diagnosed in 2011 with prostate, breast, colorectal, lung, gynaecological and skin cancers including malignant melanoma, and 9424 controls were selected from the Swedish Cancer Register and a regional health care database. Diagnostic codes [International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10)] from primary care for patients with ≥4 GP consultations registered in the year before cancer diagnosis were collected. Likelihood ratios (LRs) were calculated for variables associated with the different cancers. RESULTS Fifty-six percent of the patients had consulted a GP four or more times in the year before cancer diagnosis. Alarm symptoms or signs represented 60% of the codes with the highest LR, but only 40% of the 10 most prevalent codes. Breast lump had the highest LR, 11.9 [95% confidence interval (CI) 8.0-17.8]; abnormalities of plasma proteins had an LR of 5.0 (95% CI 3.0-8.2) and abnormal serum enzyme levels had an LR of 4.6 (95% CI 3.6-5.9). Early clinical features associated with cancer had been registered already at the first two GP consultations. CONCLUSION One out of six clinical features associated with cancer were presented by cancer patients with four or more pre-referral consultations already at the two first consultations. These early clinical features that were focal and had benign characteristics might have been missed diagnostic opportunities.
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Affiliation(s)
- Marcela Ewing
- Department of Public Health and Community Medicine/Primary Health Care, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Peter Naredi
- Department of Surgery, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Jörgen Månsson
- Department of Public Health and Community Medicine/Primary Health Care, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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