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Black GB, Khalid AF, Lyratzopoulos G, Duffy SW, Nicholson BD, Fulop NJ. Exploring the policy implementation of a holistic approach to cancer investigation in non-specific symptom pathways in England: An ethnographic study. J Health Serv Res Policy 2024:13558196241288068. [PMID: 39673231 DOI: 10.1177/13558196241288068] [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: 12/16/2024]
Abstract
OBJECTIVES This study aimed to explore the policy implementation of non-specific symptom pathways within the English National Health Service. METHODS A multi-site ethnographic project was conducted in four hospitals that contained non-specific symptom pathways between November 2021 and February 2023. The research involved observation (44 h), interviews (n = 54), patient shadowing, and document review. RESULTS The study examined how the policy concept of 'holistic' care was understood and put into practice within four non-specific symptom pathways. Several challenges associated with providing holistic care were identified. One key challenge was the conflict between delivering holistic care and meeting timed targets, such as the Faster Diagnosis Standard, due to limited availability of imaging and diagnostic tools. The interpretation of a holistic approach varied among participants, with some acknowledging that the current model did not recognise holistic care beyond cancer exclusion. The findings also revealed a lack of clarity and differing opinions on the boundaries of holistic care, resulting in wide variation in NSS pathway implementation across health care providers. Additionally, holistic investigation of non-specific symptoms in younger patients were seen to pose difficulties due to younger patients' history of health anxiety or depression, as well as concerns over radiological risk exposure. CONCLUSIONS The study highlights the complexity of implementing non-specific symptom pathways in light of standardised timed cancer targets and local cancer policies. There is a need for appropriately funded organisational models of care that prioritise holistic care in a timely manner over solely meeting cancer targets. Decision-makers should also consider the role of non-specific symptom pathways within the broader context of chronic disease management, with a particular emphasis on expanding diagnostic capacity.
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Affiliation(s)
- Georgia B Black
- Wolfson Institute of Population Health, Queen Mary University of London, UK
| | - Ahmad F Khalid
- Canadian Institutes of Health Research Health System Impact Fellow, Centre for Implementation Research, Ottawa Hospital Research Institute, Canada
| | | | - Stephen W Duffy
- Wolfson Institute of Population Health, Queen Mary University of London, UK
| | - Brian D Nicholson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
| | - Naomi J Fulop
- Institute of Epidemiology & Health Care, University College London, UK
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2
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Damhus CS, Brodersen JB, Nielsen GL. Diagnostic flow for all patients referred with non-specific symptoms of cancer to a diagnostic centre in Denmark: A descriptive study. Eur J Gen Pract 2024; 30:2296108. [PMID: 38179994 PMCID: PMC10773629 DOI: 10.1080/13814788.2023.2296108] [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: 01/13/2023] [Accepted: 12/12/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND Since 2012, Cancer Patient Pathways for Non-specific Symptoms and Signs of Cancer (NSSC-CPP) have been implemented in Scandinavia and UK. OBJECTIVES This study aimed to describe the diagnostic flow for all patients referred from 1 January to 30 June 2020 to the NSSC-CPP in the Diagnostic Centre in Farsø (DC-F), Denmark. METHODS During the study period, we prospectively recorded information on the diagnostic flow, including: pathway trajectory, symptoms and findings leading to referral, diagnostic procedures and diagnoses at the end of DC Farsø work-up and within 6-months for all patients referred to the NSSC-CPP in DC Farsø using electronic patient files and the Danish National Patient Registry (DNPR). RESULTS Of the 314 referrals to DC Farsø, 227 had diagnostic work-up in DC Farsø, the remaining were redirected to other CPPs (n = 11), outpatient clinics (n = 45) or redirected to general practice (n = 25). Of total referrals, 25 (8%) received a malignant diagnosis, 20 (6%) a non-malignant but clinically relevant diagnosis with initiation of treatment, 16 (5%) a non-malignant diagnosis but no treatment needed and in 253 (81%) referrals no severe new condition was diagnosed. Two (1%) additional malignancies were diagnosed within a 6-month follow-up period. CONCLUSION By tracking all patients referred to the NSSC-CPP in DC Farsø, including those redirected, this is the first study to describe the diagnostic flow for all patients referred to a diagnostic centre in Denmark. This knowledge is important for further organisation and planning of the NSSC-CPP.
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Affiliation(s)
- Christina Sadolin Damhus
- The Centre of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- The Research Unit for General Practice in Region Zealand, Denmark
| | - John Brandt Brodersen
- The Centre of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- The Research Unit for General Practice in Region Zealand, Denmark
- Department of Community Medicine, General Practice Research Unit, Faculty of Health Sciences, UiT, The Arctic University of Norway, Tromsø, Norway
| | - Gunnar Lauge Nielsen
- Department of Internal Medicine, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark
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3
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Jones K, Chandran A, Rance J. Rapid diagnostic pathways for prostate cancer: A realist synthesis. J Cancer Policy 2024; 42:100514. [PMID: 39557195 DOI: 10.1016/j.jcpo.2024.100514] [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: 07/29/2024] [Revised: 10/23/2024] [Accepted: 11/03/2024] [Indexed: 11/20/2024]
Abstract
INTRODUCTION The NHS Long-term Plan outlines a number of approaches to address delays and diagnose three out of four cancers at an early stage, and yet patients regularly experience delays to diagnosis. Attempts to address such delays include the implementation of a number of rapid diagnosis pathways (RDPs). This realist review explores rapid diagnosis pathways for prostate cancer, identifying approaches to RDPs, as well as generating theories regarding what works, for whom and under which circumstances. METHODS This is a realist evidence synthesis. The questions and approach are informed by patient and public involvement (PPI). We conducted a scoping review to generate initial programme theories and then refined these through further search processes. As a realist review, we do not focus on a specific data type or outcome, rather we include qualitative and quantitative data to inform theories comprised of contexts, mechanisms, and outcomes (CMO chains). RESULTS Six studies were included in our scoping review; twenty studies were included in the second review. The studies include qualitative and quantitative data. We identified three broad themes: Primary care, organizational factors, and patient experience. CONCLUSIONS/ RECOMMENDATIONS We recommend the involvement of adjoining services (e.g. general practice and radiology) in the planning of prostate cancer RDPs and emphasize the importance of clear communication with patients.
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Grønnemose RB, Hansen PS, Worsøe Laursen S, Gerke O, Kjellberg J, Lykkegaard J, Thye-Rønn C, Høilund-Carlsen PF, Thye-Rønn P. Risk of cancer and serious disease in Danish patients with urgent referral for serious non-specific symptoms and signs of cancer in Funen 2014-2021. Br J Cancer 2024; 130:1304-1315. [PMID: 38409600 PMCID: PMC11014902 DOI: 10.1038/s41416-024-02620-y] [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: 07/07/2023] [Revised: 02/12/2024] [Accepted: 02/12/2024] [Indexed: 02/28/2024] Open
Abstract
BACKGROUND In 2011, as the first European country, Denmark introduced the non-organ-specific cancer patient pathway (CPP) for patients presenting with non-specific symptoms and signs of cancer (NSSC). The proportion of patients with cancer over time is unknown. METHODS A retrospective cohort study of all patients with a NSSC-CPP investigational course in the province of Funen to the Diagnostic Centre in Svendborg from 2014 to 2021 was performed to evaluate the proportion of patients with cancer and serious disease over time. RESULTS A total of 6698 patients were referred to the NSSC-CPP of which 20.2% had cancer. While the crude referral rate increased from 114 per 100,000 people in 2014 and stabilised to around 214 in 2017-2021, the cancer detection rate of the total yearly new cancers in Funen diagnosed through the NSSC-CPP in DC Svendborg increased from 3 to 6%. CONCLUSIONS With now high and stable conversion and crude referral rates, the NSSC-CPP is one of the largest CPPs in Denmark as measured by the number of new cancer cases found. Similar urgent referral programmes in other countries might fill an unmet medical need for patients presenting with serious non-specific symptoms and signs of cancer in general practice.
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Affiliation(s)
| | - Per Syrak Hansen
- Diagnostic Centre, Svendborg Hospital, Odense University Hospital, Svendborg, Denmark
| | | | - Oke Gerke
- Department of Nuclear Medicine, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Jakob Kjellberg
- VIVE, The Danish Centre for Social Science Research, Copenhagen, Denmark
| | - Jesper Lykkegaard
- Research Unit of General Practice, University of Southern Denmark, Odense, Denmark
| | - Clara Thye-Rønn
- Diagnostic Centre, Svendborg Hospital, Odense University Hospital, Svendborg, Denmark
| | | | - Peter Thye-Rønn
- Diagnostic Centre, Svendborg Hospital, Odense University Hospital, Svendborg, Denmark.
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Monroy-Iglesias MJ, Martin S, Cargaleiro C, Jones G, Steward L, Murtagh C, Bruno F, Millwaters J, Schizas A, Watson H, Haire A, Haire K, Moss CL, Russell B, Srirajaskanthan R, Van Hemelrijck M, Dolly S. Real-world data evaluating Guy's rapid diagnostic clinic as an alternate pathway for patients with FIT levels below 10. BMJ Open 2024; 14:e080285. [PMID: 38626962 PMCID: PMC11029265 DOI: 10.1136/bmjopen-2023-080285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 03/13/2024] [Indexed: 04/19/2024] Open
Abstract
OBJECTIVE To analyse the effectiveness of rapid diagnostic clinics (RDCs) as an alternative pathway for patients with concerning symptoms and a faecal immunochemical test (FIT) result <10. Our primary endpoint was rate of colorectal cancer (CRC) detection. Second endpoints were rates of other cancers and gastrointestinal (GI) serious benign conditions. Finally, we analysed the specific pathway followed by FIT <10 patients with cancer at Guy's and St Thomas NHS Foundation Trust (GSTT) RDC. DESIGN A retrospective and prospective cohort study. SETTING GSTT RDC, one of England's largest single-centre RDCs. Sociodemographic and clinical characteristics of FIT <10 patients were analysed descriptively. PARTICIPANTS Patients with an FIT result <10, seen at GSTT RDC between 1 January 2020 and 5 May 2023. RESULTS A total of 1299 patients with an FIT<10 were seen at GSTT RDC between January 2020 and May 2023. Of these, 66% (n=861) reported weight loss, 62% (n=805) pain, 37% (n=481) fatigue, 34% (n=444) were anaemic and 23% (n=301) had nausea and vomiting. Among these patients, 7% (n=88) received a cancer diagnosis, 36% (n=462) were identified as having a serious benign condition. Within the patients with cancer, 9% (n=8) were diagnosed with CRC. Among patients with serious benign conditions, 7% (n=31) were referred to colorectal, hepatopancreatobiliary, or upper GI specialists. CONCLUSION This study demonstrates the effectiveness of RDCs as an alternate pathway for FIT <10 patients with ongoing clinical concerns. These results contribute to enhancing patient care and optimising resource allocation within the healthcare system.
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Affiliation(s)
| | - Sabine Martin
- Medical Oncology, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Carlos Cargaleiro
- Medical Oncology, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Geraint Jones
- Medical Oncology, Guy's and St Thomas' Hospitals NHS Trust, London, UK
- Southeast London Cancer Alliance, London, UK
| | - Lindsay Steward
- Medical Oncology, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Colette Murtagh
- Medical Oncology, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Flaminia Bruno
- Medical Oncology, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Juliet Millwaters
- Medical Oncology, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Alexis Schizas
- Department of Colorectal Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Harriet Watson
- Department of Colorectal Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Anna Haire
- Translational Oncology and Urology Research, King's College London, London, UK
| | - Kate Haire
- Southeast London Cancer Alliance, London, UK
| | | | - Beth Russell
- Translational Oncology and Urology Research, King's College London, London, UK
| | | | | | - Saoirse Dolly
- Medical Oncology, Guy's and St Thomas' Hospitals NHS Trust, London, UK
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Wheelwright SJ, Russ S, Mold F, Armes J, Harder H. Symptomatic presentation of cancer in primary care: a scoping review of patients' experiences and needs during the cancer diagnostic pathway. BMJ Open 2024; 14:e076527. [PMID: 38508614 PMCID: PMC10961516 DOI: 10.1136/bmjopen-2023-076527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 02/15/2024] [Indexed: 03/22/2024] Open
Abstract
OBJECTIVES The objective was to map the experiences and needs of patients presenting with symptoms of suspected cancer in the primary care interval (from when they first present to primary care to their first appointment or referral to a secondary or tertiary level healthcare facility). DESIGN This was a scoping review. INCLUSION CRITERIA Studies or reports written in English which included primary data on the primary care interval experiences and/or needs of adult patients presenting with new symptoms of suspected cancer were eligible. Studies which only included patients with secondary or recurring cancer, conference abstracts and reviews were excluded. No date limits were applied. METHODS The Joanna Briggs Institute method for Scoping Reviews guided screening, report selection and data extraction. At least two independent reviewers contributed to each stage. Medline, CINAHL, PsychInfo, Embase and Web of Science were searched and several grey literature resources. Relevant quantitative findings were qualitised and integrated with qualitative findings. A thematic analysis was carried out. RESULTS Of the 4855 records identified in the database search, 18 were included in the review, along with 13 identified from other sources. The 31 included studies were published between 2002 and 2023 and most (n=17) were conducted in the UK. Twenty subthemes across four themes (patient experience, interpersonal, healthcare professional (HCP) skills, organisational) were identified. No studies included patient-reported outcome measures. Patients wanted (1) to feel heard and understood by HCPs, (2) a plan to establish what was causing their symptoms, and (3) information about the next stages of the diagnostic process. CONCLUSIONS Scoping review findings can contribute to service planning as the cancer diagnostic pathway for symptomatic presentation of cancer evolves. The effectiveness of this pathway should be evaluated not only in terms of clinical outcomes, but also patient-reported outcomes and experience, along with the perspectives of primary care HCPs.
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Affiliation(s)
| | - Stephanie Russ
- Brighton & Sussex Medical School, University of Sussex, Brighton, UK
| | - Freda Mold
- Department of Health Care Management & Policy, University of Surrey, Guildford, Surrey, UK
| | - Jo Armes
- School of Health Sciences, University of Surrey, Guildford, Surrey, UK
| | - Helena Harder
- Brighton & Sussex Medical School, University of Sussex, Brighton, UK
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Wale A, Okolie C, Everitt J, Hookway A, Shaw H, Little K, Lewis R, Cooper A, Edwards A. The Effectiveness and Cost-Effectiveness of Community Diagnostic Centres: A Rapid Review. Int J Public Health 2024; 69:1606243. [PMID: 38322307 PMCID: PMC10844947 DOI: 10.3389/ijph.2024.1606243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 01/08/2024] [Indexed: 02/08/2024] Open
Abstract
Objectives: To examine the effectiveness of community diagnostic centres as a potential solution to increasing capacity and reducing pressure on secondary care in the UK. Methods: A comprehensive search for relevant primary studies was conducted in a range of electronic sources in August 2022. Screening and critical appraisal were undertaken by two independent reviewers. There were no geographical restrictions or limits to year of publication. A narrative synthesis approach was used to analyse data and present findings. Results: Twenty primary studies evaluating twelve individual diagnostic centres were included. Most studies were specific to cancer diagnosis and evaluated diagnostic centres located within hospitals. The evidence of effectiveness appeared mixed. There is evidence to suggest diagnostic centres can reduce various waiting times and reduce pressure on secondary care. However, cost-effectiveness may depend on whether the diagnostic centre is running at full capacity. Most included studies used weak methodologies that may be inadequate to infer effectiveness. Conclusion: Further well-designed, quality research is needed to better understand the effectiveness and cost-effectiveness of community diagnostic centres.
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Affiliation(s)
- Alesha Wale
- Public Health Wales NHS Trust, Cardiff, United Kingdom
| | | | | | - Amy Hookway
- Public Health Wales NHS Trust, Cardiff, United Kingdom
| | - Hannah Shaw
- Public Health Wales NHS Trust, Cardiff, United Kingdom
| | - Kirsty Little
- Public Health Wales NHS Trust, Cardiff, United Kingdom
| | - Ruth Lewis
- North Wales Medical School, Health and Care Research Wales Evidence Centre, PRIME Centre, Wales, Bangor University, Bangor, United Kingdom
| | - Alison Cooper
- Division of Population Medicine, Health and Care Research Wales Evidence Centre, PRIME Centre Wales, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Adrian Edwards
- Division of Population Medicine, Health and Care Research Wales Evidence Centre, PRIME Centre Wales, School of Medicine, Cardiff University, Cardiff, United Kingdom
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8
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Gong X, Pei Y, Zhang M, Wu B. Quality of death among older adults in China: The role of medical expenditure and timely medical treatment. J Aging Soc Policy 2023; 35:667-682. [PMID: 35608353 DOI: 10.1080/08959420.2022.2079907] [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: 08/03/2020] [Accepted: 03/30/2021] [Indexed: 10/18/2022]
Abstract
Medical expenses in the last year of life consume a large portion of healthcare expenditures, yet little is known about the relationship between medical expenditures in the last year of life and quality of death. Few empirical studies have investigated the association between timely medical treatment before dying and quality of death. This study aimed to examine the associations between medical expenditures in the last year of life, timely medical treatment before dying, and quality of death. Data derived from the Chinese Longitudinal Healthy Longevity Survey (CLHLS), the largest national representative study of the oldest-old in China. Results from multinomial logistic regression suggested that higher medical expenses in the last year of life and lack of timely medical treatment before dying are associated with lower quality of death. These findings highlight an urgent need for strengthening education on death and dying, developing hospice and palliative care services, and improving pain management at the end of life in China.
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Affiliation(s)
- Xiuquan Gong
- Professor, Social Science and Public Administration, East China University of Science and Technology, Shanghai, China
| | - Yaolin Pei
- Research Scientist. Rory Meyers College of Nursing, New York University, NY, USA
| | - Min Zhang
- Master student, Social Science and Public Administration, East China University of Science and Technology, Shanghai, China
| | - Bei Wu
- Dean's Professor in Global Health, Rory Meyers College of Nursing, New York University, NY, USA
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9
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Hudnut AG, Hubbell E, Venn O, Church TR. Modeled residual current cancer risk after clinical investigation of a positive multicancer early detection test result. Cancer 2023; 129:2056-2063. [PMID: 36943898 DOI: 10.1002/cncr.34747] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 11/10/2022] [Accepted: 11/14/2022] [Indexed: 03/23/2023]
Abstract
BACKGROUND Positive results of a multi-cancer early detection (MCED) test require confirmatory diagnostic workup. Here, residual current cancer risk (RR) during the process of diagnostic resolution, including situations where the initial confirmatory test does not provide resolution, was modeled. METHODS A decision-tree framework was used to model conditional risk in a patient's journey through confirmatory diagnostic options and outcomes. The diagnostic journey assumed that cancer signal detection (a positive MCED test result) had already led to a transition from screening to diagnosis and began with an initial positive predictive value (PPV) from the positive result. Evaluation of a most probable (top) predicted cancer signal origin (CSO) and then a second-most probable predicted CSO followed. Under the assumption that the top- and second-predicted CSOs were each followed by a targeted confirmatory test, the RR was estimated for each subsequent scenario. RESULTS For an initial MCED test result with typical performance characteristics modeled (PPV, 40%; top-predicted CSO accuracy, 90%), after a negative initial confirmatory test (sensitivity, 70%, 90%, or 100%) the RR ranged from 6% to 20%. A second-predicted CSO (accuracy, 50%), after a negative second confirmatory test, still provided a significant RR (3%-18%) in comparison with the National Institute for Health and Care Excellence-recommended cancer risk threshold warranting investigation in symptomatic individuals (3%). With a 40% PPV for an MCED test and 90% specificity for a confirmatory test, the risk of incidental findings after one or two confirmatory tests was 6% and 12%, respectively. CONCLUSIONS These results may illustrate the impact of a positive MCED test on follow-up decision-making.
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Affiliation(s)
- Andrew G Hudnut
- Family Medicine, Sutter Medical Group, Elk Grove, California, USA
| | - Earl Hubbell
- GRAIL, LLC, a subsidiary of Illumina, Inc., Menlo Park, California, USA
| | - Oliver Venn
- GRAIL, LLC, a subsidiary of Illumina, Inc., Menlo Park, California, USA
| | - Timothy R Church
- Division of Environmental Health Sciences, University of Minnesota, Minneapolis, Minnesota, USA
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10
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Lawrence R, Watters M, Davies CR, Pantel K, Lu YJ. Circulating tumour cells for early detection of clinically relevant cancer. Nat Rev Clin Oncol 2023:10.1038/s41571-023-00781-y. [PMID: 37268719 DOI: 10.1038/s41571-023-00781-y] [Citation(s) in RCA: 63] [Impact Index Per Article: 63.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2023] [Indexed: 06/04/2023]
Abstract
Given that cancer mortality is usually a result of late diagnosis, efforts in the field of early detection are paramount to reducing cancer-related deaths and improving patient outcomes. Increasing evidence indicates that metastasis is an early event in patients with aggressive cancers, often occurring even before primary lesions are clinically detectable. Metastases are usually formed from cancer cells that spread to distant non-malignant tissues via the blood circulation, termed circulating tumour cells (CTCs). CTCs have been detected in patients with early stage cancers and, owing to their association with metastasis, might indicate the presence of aggressive disease, thus providing a possible means to expedite diagnosis and treatment initiation for such patients while avoiding overdiagnosis and overtreatment of those with slow-growing, indolent tumours. The utility of CTCs as an early diagnostic tool has been investigated, although further improvements in the efficiency of CTC detection are required. In this Perspective, we discuss the clinical significance of early haematogenous dissemination of cancer cells, the potential of CTCs to facilitate early detection of clinically relevant cancers, and the technological advances that might improve CTC capture and, thus, diagnostic performance in this setting.
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Affiliation(s)
- Rachel Lawrence
- Centre for Biomarkers and Therapeutics, Barts Cancer Institute, Queen Mary University of London, London, UK
| | - Melissa Watters
- Barts and London School of Medicine and Dentistry, Queen Mary University London, London, UK
| | - Caitlin R Davies
- Centre for Biomarkers and Therapeutics, Barts Cancer Institute, Queen Mary University of London, London, UK
| | - Klaus Pantel
- Department of Tumour Biology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Yong-Jie Lu
- Centre for Biomarkers and Therapeutics, Barts Cancer Institute, Queen Mary University of London, London, UK.
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11
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Anthony BF, Disbeschl S, Goulden N, Hendry A, Hiscock J, Hoare Z, Roberts J, Rose J, Surgey A, Williams NH, Walker D, Neal R, Wilkinson C, Edwards RT. Earlier cancer diagnosis in primary care: a feasibility economic analysis of ThinkCancer! BJGP Open 2023; 7:BJGPO.2022.0130. [PMID: 36543386 DOI: 10.3399/bjgpo.2022.0130] [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: 09/02/2022] [Revised: 12/07/2022] [Accepted: 12/18/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND UK cancer survival rates are much lower compared with other high-income countries. In primary care, there are opportunities for GPs and other healthcare professionals to act more quickly in response to presented symptoms that might represent cancer. ThinkCancer! is a complex behaviour change intervention aimed at primary care practice teams to improve the timely diagnosis of cancer. AIM To explore the costs of delivering the ThinkCancer! intervention to expedite cancer diagnosis in primary care. DESIGN & SETTING Feasibility economic analysis using a micro-costing approach, which was undertaken in 19 general practices in Wales, UK. METHOD From an NHS perspective, micro-costing methodology was used to determine whether it was feasible to gather sufficient economic data to cost the ThinkCancer! INTERVENTION Owing to the COVID-19 pandemic, ThinkCancer! was mainly delivered remotely online in a digital format. Budget impact analysis (BIA) and sensitivity analysis were conducted to explore the costs of face-to-face delivery of the ThinkCancer! intervention as intended pre-COVID-19. RESULTS The total costs of delivering the ThinkCancer! intervention across 19 general practices in Wales was £25 030, with an average cost per practice of £1317 (standard deviation [SD]: 578.2). Findings from the BIA indicated a total cost of £34 630 for face-to-face delivery. CONCLUSION Data collection methods were successful in gathering sufficient health economics data to cost the ThinkCancer! INTERVENTION Results of this feasibility study will be used to inform a future definitive economic evaluation alongside a pragmatic randomised controlled trial (RCT).
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Affiliation(s)
- Bethany Fern Anthony
- Centre for Health Economics and Medicines Evaluation (CHEME), Bangor University, Bangor, UK
| | - Stefanie Disbeschl
- North Wales Centre for Primary Care Research, Bangor University, Bangor, UK
| | | | - Annie Hendry
- North Wales Centre for Primary Care Research, Bangor University, Bangor, UK
| | - Julia Hiscock
- North Wales Centre for Primary Care Research, Bangor University, Bangor, UK
| | - Zoe Hoare
- NWORTH, Bangor University, Bangor, UK
| | - Jessica Roberts
- North Wales Centre for Primary Care Research, Bangor University, Bangor, UK
| | - Jan Rose
- National Cancer Research Institute (NCRI), Consumer Member, London, UK
| | - Alun Surgey
- North Wales Centre for Primary Care Research, Bangor University, Bangor, UK
| | - Nefyn Howard Williams
- Department of Primary Care and Mental Health, University of Liverpool, Liverpool, UK
| | - Daniel Walker
- North Wales Centre for Primary Care Research, Bangor University, Bangor, UK
| | - Richard Neal
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Clare Wilkinson
- North Wales Centre for Primary Care Research, Bangor University, Bangor, UK
| | - Rhiannon Tudor Edwards
- Centre for Health Economics and Medicines Evaluation (CHEME), Bangor University, Bangor, UK
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12
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Bourkas AN, Menard A, Tarulli E, Jodoin L, Biagi JJ. Impact of an Accelerated Diagnostic Assessment Program on the Timeliness of Cancer Diagnosis and Treatment. JCO Oncol Pract 2023; 19:e511-e519. [PMID: 36657095 DOI: 10.1200/op.22.00551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
PURPOSE The Accelerated Diagnostic Assessment Program (ADAP) manages patients with imaging abnormalities, with or without concomitant symptoms, where cancer is suspected. The ADAP is offered to primary care practitioners and emergency departments with cases triaged by a medical oncologist. METHODS We performed a retrospective patient chart review of electronic medical records from January 2019 until June 2021 to validate the program. We collected information on the referral pathways, patient demographics, wait-times, and diagnostic results. The control group consisted of outpatients who were referred for biopsy over a 1-year period outside the ADAP stream. Statistical analyses were performed using IBM SPSS software. RESULTS Of the 97 patients included, 54% were female, with ages ranging from 18 to 96 years. Twenty-nine percent (n = 20) of the malignant cases were incidental findings. Most patients referred to the ADAP were diagnosed with a malignancy (71%; n = 69), comprising hematologic (45%; n = 31), GI (26%; n = 18), or other cancers (29%; n = 20). The ADAP had decreased wait-times from referral to biopsy collection (17.6 days ± 10.7 [standard deviation (SD)]; n = 43) when compared with the control group (41.2 days ± 40.0 [SD]; n = 67; P < .001). ADAP patients with malignancies saw a treating specialist 7.6 ± 7.6 days [SD] after their follow-up appointment at the ADAP. CONCLUSION The ADAP accelerated time to biopsy in a statistically significant manner when compared with age-, referring physician-, and biopsy site-matched controls. It also outperformed national and provincial standards, suggesting that its model addresses a gap in care by providing an underserved population timely access to diagnosis and treatment.
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Affiliation(s)
- Adrienn N Bourkas
- School of Medicine, Queen's University, Kingston, Ontario, Canada.,Department of Oncology, Queen's University, Kingston, Ontario, Canada
| | - Alexandre Menard
- Department of Diagnostic Radiology, Queen's University, Kingston, Ontario, Canada
| | - Emidio Tarulli
- Department of Diagnostic Radiology, Queen's University, Kingston, Ontario, Canada
| | - Leah Jodoin
- The Cancer Center of Southeastern Ontario, Kingston Health Sciences Center, Kingston, Ontario, Canada.,Faculty of Health Sciences School of Nursing, Queen's University, Kingston, Ontario, Canada
| | - James J Biagi
- School of Medicine, Queen's University, Kingston, Ontario, Canada.,Department of Oncology, Queen's University, Kingston, Ontario, Canada.,The Cancer Center of Southeastern Ontario, Kingston Health Sciences Center, Kingston, Ontario, Canada
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13
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Smith P, Moody G, Clarke E, Hiscock J, Cannings-John R, Townson J, Edwards A, Quinn-Scoggins HD, Sewell B, Jones D, Lloydwin C, Thomas S, Casey D, Lloyd-Bennett C, Stanton H, Lugg-Widger FV, Huws D, Watkins A, Newton G, Thomas AM, McCutchan GM, Brain K. Protocol for a feasibility study of a cancer symptom awareness campaign to support the rapid diagnostic centre referral pathway in a socioeconomically deprived area: Targeted Intensive Community-based campaign To Optimise Cancer awareness (TIC-TOC). BMJ Open 2022; 12:e063280. [PMID: 36223970 PMCID: PMC9562715 DOI: 10.1136/bmjopen-2022-063280] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION Rapid diagnostic centres (RDCs) are being implemented across the UK to accelerate the assessment of vague suspected cancer symptoms. Targeted behavioural interventions are needed to augment RDCs that serve socioeconomically deprived populations who are disproportionately affected by cancer, have lower cancer symptom awareness and are less likely to seek help for cancer symptoms. The aim of this study is to assess the feasibility and acceptability of delivering and evaluating a community-based vague cancer symptom awareness intervention in an area of high socioeconomic deprivation. METHODS AND ANALYSIS Intervention materials and messages were coproduced with local stakeholders in Cwm Taf Morgannwg, Wales. Cancer champions will be trained to deliver intervention messages and distribute intervention materials using broadcast media (eg, local radio), printed media (eg, branded pharmacy bags, posters, leaflets), social media (eg, Facebook) and attending local community events. A cross-sectional questionnaire will include self-reported patient interval (time between noticing symptoms to contacting the general practitioner), cancer symptom recognition, cancer beliefs and barriers to presentation, awareness of campaign messages, healthcare resource use, generic quality of life and individual and area-level deprivation indicators. Consent rates and proportion of missing data for patient questionnaires (n=189) attending RDCs will be measured. Qualitative interviews and focus groups will assess intervention acceptability and barriers/facilitators to delivery. ETHICS AND DISSEMINATION Ethical approval for this study was given by the London-West London & GTAC Research Ethics (21/LO/0402). This project will inform a potential future controlled study to assess intervention effectiveness in reducing the patient interval for vague cancer symptoms. The results will be critical to informing national policy and practice regarding behavioural interventions to support RDCs in highly deprived populations.
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Affiliation(s)
- Pamela Smith
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | | | - Eleanor Clarke
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Julia Hiscock
- North Wales Centre for Primary Care Research, Bangor Institute for Health and Medical Research, Bangor University, Bangor University, Wrexham, UK
| | | | - Julia Townson
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Adrian Edwards
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | | | - Bernadette Sewell
- Swansea Centre for Health Economics, Swansea University, Swansea, Wales, UK
| | - Daniel Jones
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | | | - Sara Thomas
- Cwm Taf Public Health Team, Public Health Wales, Public Health Wales, Merthyr Tydfil, UK
| | - Dawn Casey
- Cwm Taf Morgannwg University Health Board, Cwm Taf, UK
| | | | - Helen Stanton
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | | | - Dyfed Huws
- Public Health Wales, Welsh Cancer Intelligence & Surveillance Unit, Cardiff, Wales, UK
- Population Data Science, Swansea University Medical School, Swansea University, Swansea, West Glamorgan, UK
| | - Angela Watkins
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Gareth Newton
- Centre for Trials Research, Cardiff University, Cardiff, UK
- Patient and Public Involvement, Cardiff University, Cardiff, UK
| | | | - Grace M McCutchan
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Kate Brain
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
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14
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Menon U, Weller D, Falborg AZ, Jensen H, Butler J, Barisic A, Knudsen AK, Bergin RJ, Brewster DH, Cairnduff V, Fourkala EO, Gavin AT, Grunfeld E, Harland E, Kalsi J, Law RJ, Lin Y, Turner D, Neal RD, White V, Harrison S, Reguilon I, Lynch C, Vedsted P. Diagnostic routes and time intervals for ovarian cancer in nine international jurisdictions; findings from the International Cancer Benchmarking Partnership (ICBP). Br J Cancer 2022; 127:844-854. [PMID: 35618787 PMCID: PMC9427750 DOI: 10.1038/s41416-022-01844-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 01/21/2022] [Accepted: 05/04/2022] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND International Cancer Benchmarking Partnership Module 4 reports the first international comparison of ovarian cancer (OC) diagnosis routes and intervals (symptom onset to treatment start), which may inform previously reported variations in survival and stage. METHODS Data were collated from 1110 newly diagnosed OC patients aged >40 surveyed between 2013 and 2015 across five countries (51-272 per jurisdiction), their primary-care physicians (PCPs) and cancer treatment specialists, supplement by treatment records or clinical databases. Diagnosis routes and time interval differences using quantile regression with reference to Denmark (largest survey response) were calculated. RESULTS There were no significant jurisdictional differences in the proportion diagnosed with symptoms on the Goff Symptom Index (53%; P = 0.179) or National Institute for Health and Care Excellence NG12 guidelines (62%; P = 0.946). Though the main diagnosis route consistently involved primary-care presentation (63-86%; P = 0.068), onward urgent referral rates varied significantly (29-79%; P < 0.001). In most jurisdictions, diagnostic intervals were generally shorter and other intervals, in particular, treatment longer compared to Denmark. CONCLUSION This study highlights key intervals in the diagnostic pathway where improvements could be made. It provides the opportunity to consider the systems and approaches across different jurisdictions that might allow for more timely ovarian cancer diagnosis and treatment.
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Affiliation(s)
- Usha Menon
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, University College London, London, UK.
| | - David Weller
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | | | - Henry Jensen
- Research Unit for General Practice, Aarhus, Denmark
| | - John Butler
- The Royal Marsden NHS Foundation Trust, London, UK
| | | | - Anne Kari Knudsen
- European Palliative Care Research Centre (PRC), Department of Oncology, Oslo, Norway
- University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Rebecca J Bergin
- Cancer Epidemiology Division, Cancer Council Victoria, Melbourne, VIC, Australia
- Department of General Practice, University of Melbourne, Melbourne, VIC, Australia
| | - David H Brewster
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
- Scottish Cancer Registry, Edinburgh, UK
| | - Victoria Cairnduff
- Northern Ireland Cancer Registry, Queen's University Belfast, Belfast, UK
| | - Evangelia Ourania Fourkala
- Gynaecological Cancer Research Centre, Women's Cancer, Institute for Women's Health, University College London, London, UK
| | - Anna T Gavin
- Northern Ireland Cancer Registry, Queen's University Belfast, Belfast, UK
| | - Eva Grunfeld
- Health Services Research Program, Ontario Institute for Cancer Research, Toronto, Ontario, Canada
| | - Elizabeth Harland
- Department of Epidemiology and Cancer Registry, CancerCare Manitoba, Winnipeg, Canada
| | - Jatinderpal Kalsi
- Gynaecological Cancer Research Centre, Women's Cancer, Institute for Women's Health, University College London, London, UK
| | - Rebecca-Jane Law
- North Wales Centre for Primary Care Research, Bangor University, Wrexham, UK
| | - Yulan Lin
- European Palliative Care Research Centre (PRC), Department of Oncology, Oslo, Norway
| | - Donna Turner
- Population Oncology, Cancer Care Manitoba, Winnipeg, Canada
| | - Richard D Neal
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Victoria White
- School of Psychology Deakin University, Geelong, VIC, Australia
- Centre for Behavioral Research in Cancer, Cancer Council Victoria, Melbourne, VIC, Australia
| | - Samantha Harrison
- International Cancer Benchmarking Partnership, Cancer Research UK, Stratford, UK
| | - Irene Reguilon
- International Cancer Benchmarking Partnership, Cancer Research UK, Stratford, UK
| | - Charlotte Lynch
- International Cancer Benchmarking Partnership, Cancer Research UK, Stratford, UK
| | - Peter Vedsted
- International Cancer Benchmarking Partnership, Cancer Research UK, Stratford, UK
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15
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Maxwell SS, Weller D. Lung cancer and Covid-19: lessons learnt from the pandemic and where do we go from here? NPJ Prim Care Respir Med 2022; 32:19. [PMID: 35637231 PMCID: PMC9151755 DOI: 10.1038/s41533-022-00283-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 05/10/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - David Weller
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
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16
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Jobling IT, Waddington C, Lee D, Crawford SM. Piloting a novel cancer care pathway: socioeconomic background as a barrier to access. Clin Med (Lond) 2022; 22:241-245. [PMID: 38589083 DOI: 10.7861/clinmed.2021-0716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND The multidisciplinary diagnostic clinic (MDC) model for 'non-specific' symptoms has been piloted in the UK. We aimed to assess the degree to which the MDC pathway was influenced by socioeconomic factors. METHODS We collected data for all patients referred to the MDC from 01 January 2017 - 28 March 2019. Indices of multiple deprivation (IMD) scores were matched to patients' postcodes and referring general practitioner (GP) location. Socioeconomic data for MDC patients was compared with all other cancer patients diagnosed in the MDC's base hospital, Airedale General Hospital (AGH), in 2018. Statistical significance was tested using the Mann-Whitney U test and Spearman's rank correlation. RESULTS No significant difference was found between MDC pathway and the rest of AGH when comparing social deprivation of patients. There was a moderate negative correlation between the IMD associated with the location of GP premises and the number of referrals; practices in more deprived locations referred fewer patients (p≤0.025). CONCLUSION The MDC pathway referral rate seems to be affected by social deprivation in a similar manner to other cancer diagnosis pathways. Our work highlights the importance of engaging GP practices with socially deprived populations as the MDC programme is rolled out across the UK.
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17
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Vázquez-Serrano JI, Peimbert-García RE, Cárdenas-Barrón LE. Discrete-Event Simulation Modeling in Healthcare: A Comprehensive Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:12262. [PMID: 34832016 PMCID: PMC8625660 DOI: 10.3390/ijerph182212262] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/12/2021] [Accepted: 11/13/2021] [Indexed: 11/26/2022]
Abstract
Discrete-event simulation (DES) is a stochastic modeling approach widely used to address dynamic and complex systems, such as healthcare. In this review, academic databases were systematically searched to identify 231 papers focused on DES modeling in healthcare. These studies were sorted by year, approach, healthcare setting, outcome, provenance, and software use. Among the surveys, conceptual/theoretical studies, reviews, and case studies, it was found that almost two-thirds of the theoretical articles discuss models that include DES along with other analytical techniques, such as optimization and lean/six sigma, and one-third of the applications were carried out in more than one healthcare setting, with emergency departments being the most popular. Moreover, half of the applications seek to improve time- and efficiency-related metrics, and one-third of all papers use hybrid models. Finally, the most popular DES software is Arena and Simul8. Overall, there is an increasing trend towards using DES in healthcare to address issues at an operational level, yet less than 10% of DES applications present actual implementations following the modeling stage. Thus, future research should focus on the implementation of the models to assess their impact on healthcare processes, patients, and, possibly, their clinical value. Other areas are DES studies that emphasize their methodological formulation, as well as the development of frameworks for hybrid models.
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Affiliation(s)
- Jesús Isaac Vázquez-Serrano
- School of Engineering and Sciences, Tecnologico de Monterrey, Monterrey 64849, Northeast Nuevo Leon, Mexico; (J.I.V.-S.); (L.E.C.-B.)
| | - Rodrigo E. Peimbert-García
- School of Engineering and Sciences, Tecnologico de Monterrey, Monterrey 64849, Northeast Nuevo Leon, Mexico; (J.I.V.-S.); (L.E.C.-B.)
- School of Engineering, Macquarie University, Sydney, NSW 2109, Australia
| | - Leopoldo Eduardo Cárdenas-Barrón
- School of Engineering and Sciences, Tecnologico de Monterrey, Monterrey 64849, Northeast Nuevo Leon, Mexico; (J.I.V.-S.); (L.E.C.-B.)
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18
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Erridge S, Lyratzopoulos G, Renzi C, Millar A, Lee R. Rapid Diagnostic Centres and early cancer diagnosis. Br J Gen Pract 2021; 71:487-488. [PMID: 34711557 PMCID: PMC8544161 DOI: 10.3399/bjgp21x717413] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- Simon Erridge
- Epidemiology of Cancer Healthcare Outcomes (ECHO) Group, Department of Behavioural Science and Health, University College London, London
| | - Georgios Lyratzopoulos
- ECHO Group, Department of Behavioural Science and Health, University College London, London
| | - Cristina Renzi
- ECHO Group, Department of Behavioural Science and Health, University College London, London
| | | | - Richard Lee
- The Royal Marsden and The Institute for Cancer Research National Institute for Health Research (NIHR) Biomedical Research Centre (BRC), The Royal Marsden NHS Foundation Trust, London
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19
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Moriarty Y, Lau M, Sewell B, Trubey R, Quinn-Scoggins H, Owen S, Padgett L, Kolovou V, Hepburn J, Buckle P, Playle R, Townson J, Robling M, Gilbert S, Dimitropoulou P, Edwards A, Mitchell C, Matthews M, Smits S, Wood F, Neal RD, Brain K. Randomised controlled trial and economic evaluation of a targeted cancer awareness intervention for adults living in deprived areas of the UK. Br J Cancer 2021; 125:1100-1110. [PMID: 34453114 PMCID: PMC8391006 DOI: 10.1038/s41416-021-01524-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 07/06/2021] [Accepted: 08/11/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Cancer outcomes are poor in socioeconomically deprived communities, with low symptom awareness contributing to prolonged help-seeking and advanced disease. Targeted cancer awareness interventions require evaluation. METHODS This is a randomised controlled trial involving adults aged 40+ years recruited in community and healthcare settings in deprived areas of South Yorkshire and South-East Wales. INTERVENTION personalised behavioural advice facilitated by a trained lay advisor. CONTROL usual care. Follow-up at two weeks and six months post-randomisation. PRIMARY OUTCOME total cancer symptom recognition score two weeks post-randomisation. RESULTS Two hundred and thirty-four participants were randomised. The difference in total symptom recognition at two weeks [adjusted mean difference (AMD) 0.6, 95% CI: -0.03, 1.17, p = 0.06] was not statistically significant. Intervention participants reported increased symptom recognition (AMD 0.8, 95% CI: 0.18, 1.37, p = 0.01) and earlier intended presentation (AMD -2.0, 95% CI: -3.02, -0.91, p < 0.001) at six months. "Lesser known" symptom recognition was higher in the intervention arm (2 weeks AMD 0.5, 95% CI: 0.03, 0.97 and six months AMD 0.7, 95% CI: 0.16, 1.17). Implementation cost per participant was £91.34, with no significant between-group differences in healthcare resource use post-intervention. CONCLUSIONS Improved symptom recognition and earlier anticipated presentation occurred at longer-term follow-up. The ABACus Health Check is a viable low-cost intervention to increase cancer awareness in socioeconomically deprived communities. CLINICAL TRIAL REGISTRATION ISRCTN16872545.
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Affiliation(s)
- Yvonne Moriarty
- Centre for Trials Research, Cardiff University, Cardiff, UK.
| | - Mandy Lau
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Bernadette Sewell
- Swansea Centre for Health Economics, College of Human and Health Sciences, Swansea University, Swansea, UK
| | - Rob Trubey
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Harriet Quinn-Scoggins
- PRIME Centre Wales, Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | | | - Louise Padgett
- Department of Health Sciences, University of York, York, UK
| | - Vasiliki Kolovou
- School of Sport & Health Sciences, Cardiff Metropolitan University, Cardiff, UK
| | - Julie Hepburn
- Public Involvement Community, Health and Care Research Wales Support Centre, Cardiff, UK
| | | | - Rebecca Playle
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Julia Townson
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | | | | | | | - Adrian Edwards
- PRIME Centre Wales, Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Caroline Mitchell
- Academic Unit of Primary Medical Care, University of Sheffield, Northern General Hospital, Sheffield, UK
| | | | - Stephanie Smits
- PRIME Centre Wales, Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Fiona Wood
- PRIME Centre Wales, Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Richard D Neal
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Kate Brain
- PRIME Centre Wales, Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
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20
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Characterisation and outcomes of patients referred to a regional cancer of unknown primary team: a 10-year analysis. Br J Cancer 2021; 125:1503-1510. [PMID: 34489587 PMCID: PMC8608886 DOI: 10.1038/s41416-021-01544-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 06/24/2021] [Accepted: 08/26/2021] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND In the United Kingdom, national guidance published in 2010 recommended the establishment of specialist teams to improve clinical pathways for patients presenting with malignancies of undefined primary origin (MUO) and cancer of unknown primary (CUP). This study sought to define outcomes of patients referred to a regional MUO/CUP service. METHODS Data were collected prospectively on all patients (n = 1225) referred to a regional CUP team over a 10-year period. Patient demographics, clinical, pathological and outcome data were recorded and analysed. RESULTS Confirmed CUP (cCUP) was diagnosed in 25% of patients. A primary metastatic cancer was identified in 36%, 5% were diagnosed with provisional CUP (pCUP), 27% retained the diagnosis of MUO and in 8% a non-cancer diagnosis was made. Median survival was low in all patients with a final malignant diagnosis: primary identified 9.0 months, cCUP 4.0 months, pCUP 1.5 months and MUO 1.5 months. CONCLUSIONS Patients presenting with MUO have poor outcomes irrespective of the final diagnosis. These patients need a patient-centred, streamlined, rapid diagnostic pathway. There are clear benefits to primary and secondary care teams having access to a dedicated, multidisciplinary MUO/CUP service, with clinical nurse specialists supporting the patients, to help facilitate this pathway and ensure early oncology review.
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21
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Maclean W, Limb C, Mackenzie P, Whyte MB, Benton SC, Rockall T, Jourdan I. Adoption of faecal immunochemical testing for 2-week-wait colorectal patients during the COVID-19 pandemic: an observational cohort study reporting a new service at a regional centre. Colorectal Dis 2021; 23:1622-1629. [PMID: 33068489 DOI: 10.1111/codi.15408] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 09/15/2020] [Accepted: 10/05/2020] [Indexed: 02/08/2023]
Abstract
AIM The COVID-19 pandemic has resulted in the near-complete loss of routine endoscopy services. We describe a major reorganization of service at a regional referral centre (Royal Surrey NHS Foundation Trust) to manage the crisis. Faecal immunochemical testing (FIT) was implemented for triage to make optimum use of limited diagnostic resources. Consultations were switched from face-to-face to telephone. Our aim was to evaluate the impact FIT had on resource allocation and patient diagnoses in the first 3 months of use. METHOD All colorectal 2-week-wait patient referrals were posted a pack requesting FIT and notification of telephone consultation. A prepaid envelope was included for return of the samples. At consultation, FIT was incorporated with the presenting symptoms to guide the choice of investigation and triage urgency. FIT ≥10 μg/g was interpreted as positive. Outcome data were collected prospectively and compared with retrospective audit data from prepandemic levels across 3 months. RESULTS From 26 March 2020 to 2 July 381 patients were referred who were invited to provide FIT samples and underwent telephone consultations. Three hundred and fifty eight FIT samples were returned (94%). Onward referral for colonoscopy reduced from 62% to 34% (P < 0.001). There were 14 colorectal cancers (CRC) (3.7%) diagnosed, which was not statistically different from the prepandemic level of 3.9% (P = 0.995). Twelve of the 14 patients with a CRC diagnosis had provided samples; all 12 had FIT ≥10 μg/g and were offered fast-track investigations. CONCLUSIONS The incorporation of FIT optimized the allocation of limited resources to triage those who required urgent colonic investigation for detecting CRC.
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Affiliation(s)
- William Maclean
- General Surgery, Royal Surrey NHS Foundation Trust, Guildford, UK
| | - Chris Limb
- General Surgery, Royal Surrey NHS Foundation Trust, Guildford, UK
| | - Paul Mackenzie
- General Surgery, Royal Surrey NHS Foundation Trust, Guildford, UK
| | | | - Sally C Benton
- Bowel Cancer Screening Hub, Royal Surrey NHS Foundation Trust, Guildford, UK
| | - Timothy Rockall
- General Surgery, Royal Surrey NHS Foundation Trust, Guildford, UK
| | - Iain Jourdan
- General Surgery, Royal Surrey NHS Foundation Trust, Guildford, UK
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22
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Vasilakis C, Forte P. Setting up a rapid diagnostic clinic for patients with vague symptoms of cancer: a mixed method process evaluation study. BMC Health Serv Res 2021; 21:357. [PMID: 33865373 PMCID: PMC8052708 DOI: 10.1186/s12913-021-06360-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 04/07/2021] [Indexed: 11/13/2022] Open
Abstract
Background The study sought to evaluate the impact of a Rapid Diagnostic Clinic (RDC) service designed to improve general practitioner (GP) referral processes for patients who do not meet existing referral criteria yet present with vague - but potentially concerning - symptoms of cancer. We sought to investigate how well the RDC has performed in the views of local GPs and patients, and through analysis of its activity and performance in the first two years of operation. Methods The study setting was a single, hospital-based RDC clinic in a University Health Board in South Wales. We used a mixed-method process evaluation study, including routinely collected activity and diagnosis data. All GPs were invited to participate in an online survey (34/165 responded), and a smaller group (n = 8) were interviewed individually. Two focus groups with patients and their carers (n = 7) provided in-depth personal accounts of their experiences. Results The focus groups revealed high rates of patient satisfaction with the RDC. GPs were also overwhelmingly positive about the value of the RDC to their practice. There were 574 clinic attendances between July 2017 and March 2019; the mean age of attendees was 68, 57% were female, and approximately 30% had three or more vague symptoms. Of those attending, we estimated between 42 to 71 (7.3 and 12.3%) received preliminary cancer diagnoses. Median time from GP referral to RDC appointment was 12 days; from GP referral to cancer diagnosis was 34 days. Overall, 73% of RDC patients received either a new diagnosis (suspected cancer 23.2%, non-cancer 35.9%) or an onward referral to secondary care for further investigation with no new diagnosis (13.9%), and 27% were referred to primary care with no new diagnosis. Conclusions The RDC appears to enable a good patient experience in cancer diagnosis. Patients are seen in timely fashion, and the service is highly regarded by them, their carers, and referring GPs. Although too early to draw conclusions about long-term patient outcomes, there are strong indications to suggest that this model of service provision can set higher standards for a strongly patient-centred service. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06360-0.
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Affiliation(s)
- Christos Vasilakis
- Centre for Healthcare Innovation and Improvement (CHI2), School of Management, University of Bath, Bath, UK.
| | - Paul Forte
- Centre for Healthcare Innovation and Improvement (CHI2), School of Management, University of Bath, Bath, UK
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23
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Brice SN, Harper P, Crosby T, Gartner D, Arruda E, England T, Aspland E, Foley K. Factors influencing the delivery of cancer pathways: a summary of the literature. J Health Organ Manag 2021; 35:121-139. [PMID: 33818048 PMCID: PMC9136872 DOI: 10.1108/jhom-05-2020-0192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 10/16/2020] [Accepted: 01/27/2021] [Indexed: 12/17/2022]
Abstract
PURPOSE The study aims to summarise the literature on cancer care pathways at the diagnostic and treatment phases. The objectives are to find factors influencing the delivery of cancer care pathways; to highlight any interrelating factors; to find gaps in the literature concerning areas of research; to summarise the strategies and recommendations implemented in the studies. DESIGN/METHODOLOGY/APPROACH The study used a qualitative approach and developed a causal loop diagram to summarise the current literature on cancer care pathways, from screening and diagnosis to treatment. A total of 46 papers was finally included in the analysis, which highlights the recurring themes in the literature. FINDINGS The study highlights the myriad areas of research applied to cancer care pathways. Factors influencing the delivery of cancer care pathways were classified into different albeit interrelated themes. These include access barriers to care, hospital emergency admissions, fast track diagnostics, delay in diagnosis, waiting time to treatment and strategies to increase system efficiency. ORIGINALITY/VALUE As far as the authors know, this is the first study to present a visual representation of the complex relationship between factors influencing the delivery of cancer care pathways.
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Affiliation(s)
| | - Paul Harper
- School of Mathematics
,
Cardiff University
, Cardiff,
UK
| | | | - Daniel Gartner
- School of Mathematics
,
Cardiff University
, Cardiff,
UK
| | - Edilson Arruda
- Department of Decision Analytics and Risk,
Southampton Business School
,
University of Southampton
, Southampton,
UK
- Alberto Luiz Coimbra Institute-Graduate School and Research in Engineering
,
Federal University of Rio de Janeiro
, Rio de Janeiro,
Brazil
| | - Tracey England
- Department of Decision Analytics and Risk,
Southampton Business School
,
University of Southampton
, Southampton,
UK
| | - Emma Aspland
- School of Mathematics
,
Cardiff University
, Cardiff,
UK
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24
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Dolly SO, Jones G, Allchorne P, Wheeler D, Ali S, Mukadam Y, Zheng S, Rahman L, Sindhar J, Moss CL, Harari D, Van Hemelrijck M, Cunliffe A, De Michele LV. The effectiveness of the Guy's Rapid Diagnostic Clinic (RDC) in detecting cancer and serious conditions in vague symptom patients. Br J Cancer 2021; 124:1079-1087. [PMID: 33402736 PMCID: PMC7783491 DOI: 10.1038/s41416-020-01207-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 10/28/2020] [Accepted: 11/25/2020] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Rapid Diagnostic Clinics (RDC) are being expanded nationally by NHS England. Guy's RDC established a pathway for GPs and internal referrals for patients with symptoms concerning for malignancy not suitable for a site-specific 2WW referral. However, little data assessing the effectiveness of RDC models are available in an English population. METHODS We evaluated all patients referred to Guy's RDC between December 2016 and June 2019 (n = 1341) to assess the rate of cancer diagnoses, frequency of benign conditions and effectiveness of the service. RESULTS There were 96 new cancer diagnoses (7.2%): lung (16%), haematological (13%) and colorectal (12%)-with stage IV being most frequent (40%). Median time to definitive cancer diagnosis was 28 days (IQR 15-47) and treatment 56 days (IQR 32-84). In all, 75% were suitable for treatment: surgery (26%), systemic (24%) and radiotherapy (14%). Over 180 serious non-neoplastic conditions were diagnosed (35.8%) of patients with no significant findings in two-third of patients (57.0%). CONCLUSIONS RDCs provide GPs with a streamlined pathway for patients with complex non-site-specific symptoms that can be challenging for primary care. The 7% rate of cancer diagnosis exceeds many 2WW pathways and a third of patients presented with significant non-cancer diagnoses, which justifies the need for rapid diagnostics. Rapid Diagnostic Centres (RDCs) are being rolled out nationally by NHS England and NHS Improvement as part of the NHS long-term plan. The aim is for a primary care referral pathway that streamlines diagnostics, patient journey, clinical outcomes and patient experience. This pilot study of 1341 patients provides an in-depth analysis of the largest single RDC in England. Cancer was diagnosed in 7% of patients and serious non-cancer conditions in 36%-justifying the RDC approach in vague symptom patients.
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Affiliation(s)
| | - Geraint Jones
- Guy's and St Thomas' NHS Foundation Trust (GSTT), Medical Oncology, London, UK
- South East London Cancer Alliance, London, UK
| | - Paula Allchorne
- Guy's and St Thomas' NHS Foundation Trust (GSTT), Medical Oncology, London, UK
| | - Daniel Wheeler
- King's College London, Faculty of Life Sciences and Medicine, London, UK
| | - Sunnyath Ali
- King's College London, Faculty of Life Sciences and Medicine, London, UK
| | - Yaseen Mukadam
- King's College London, Faculty of Life Sciences and Medicine, London, UK
| | - Sifan Zheng
- King's College London, Faculty of Life Sciences and Medicine, London, UK
| | - Loay Rahman
- King's College London, Faculty of Life Sciences and Medicine, London, UK
| | - Jan Sindhar
- King's College London, Faculty of Life Sciences and Medicine, London, UK
| | - Charlotte Louise Moss
- King's College London, School of Cancer and Pharmaceutical Sciences, Translational Oncology and Urology Research (TOUR), London, UK
| | - Danielle Harari
- Guy's and St Thomas' NHS Foundation Trust (GSTT), Medical Oncology, London, UK
- King's College London, Geriatric and Acute Medicine, Department of Ageing and Health, London, UK
| | - Mieke Van Hemelrijck
- King's College London, School of Cancer and Pharmaceutical Sciences, Translational Oncology and Urology Research (TOUR), London, UK
| | - Anthony Cunliffe
- Joint National Lead Macmillan GP Adviser and Joint Clinical Chair, South East London Cancer alliance, London, UK
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25
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Incidental findings in a referral pathway for non-specific cancer symptoms. Clin Imaging 2021; 77:9-12. [PMID: 33610971 DOI: 10.1016/j.clinimag.2021.01.042] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 01/19/2021] [Accepted: 01/30/2021] [Indexed: 12/21/2022]
Abstract
RATIONALE AND OBJECTIVES To determine the prevalence of incidental findings and define the rate and outcomes of further investigations in a referral pathway for patients with non-specific cancer symptoms. MATERIAL AND METHODS Incidental findings in each category of a structured report were documented and details of subsequent investigations were obtained from the local PACS and Electronic Patient Record system. RESULTS 1034 patients were included. Of these, 11% were diagnosed with cancer. The majority of patients (95%) had at least one additional finding reported. The majority of these were minor, but in 140 cases (14%), additional findings were considered to be of clinical significance. Further investigations were performed in 330 patients who did not receive a diagnosis of cancer (32%). In 301 patients (29%), further investigations were normal or non-significant. In 75 cases (7%), ongoing surveillance was required. Specialist referral was recommended for 102 patients (10%) who did not receive a diagnosis of cancer. CONCLUSIONS In this cohort, there was a high rate of non-significant incidental findings and normal further investigations. However, these risks are likely to be outweighed by the high number of cancer diagnoses and significant non-cancer findings.
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Koo MM, Unger-Saldaña K, Mwaka AD, Corbex M, Ginsburg O, Walter FM, Calanzani N, Moodley J, Rubin GP, Lyratzopoulos G. Conceptual Framework to Guide Early Diagnosis Programs for Symptomatic Cancer as Part of Global Cancer Control. JCO Glob Oncol 2021; 7:35-45. [PMID: 33405957 PMCID: PMC8081530 DOI: 10.1200/go.20.00310] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 10/06/2020] [Accepted: 11/06/2020] [Indexed: 12/15/2022] Open
Abstract
Diagnosing cancer earlier can enable timely treatment and optimize outcomes. Worldwide, national cancer control plans increasingly encompass early diagnosis programs for symptomatic patients, commonly comprising awareness campaigns to encourage prompt help-seeking for possible cancer symptoms and health system policies to support prompt diagnostic assessment and access to treatment. By their nature, early diagnosis programs involve complex public health interventions aiming to address unmet health needs by acting on patient, clinical, and system factors. However, there is uncertainty regarding how to optimize the design and evaluation of such interventions. We propose that decisions about early diagnosis programs should consider four interrelated components: first, the conduct of a needs assessment (based on cancer-site-specific statistics) to identify the cancers that may benefit most from early diagnosis in the target population; second, the consideration of symptom epidemiology to inform prioritization within an intervention; third, the identification of factors influencing prompt help-seeking at individual and system level to support the design and evaluation of interventions; and finally, the evaluation of factors influencing the health systems' capacity to promptly assess patients. This conceptual framework can be used by public health researchers and policy makers to identify the greatest evidence gaps and guide the design and evaluation of local early diagnosis programs as part of broader cancer control strategies.
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Affiliation(s)
- Minjoung Monica Koo
- Epidemiology of Cancer Healthcare and Outcomes (ECHO) Research Group, Department of Behavioural Science and Health, University College London, London, United Kingdom
| | - Karla Unger-Saldaña
- CONACYT (National Council of Science and Technology)–National Cancer Institute, Mexico City, Mexico
| | - Amos D. Mwaka
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | - Ophira Ginsburg
- Perlmutter Cancer Center and the Department of Population Health, NYU Grossman School of Medicine, NYU Langone Health, New York, NY
| | - Fiona M. Walter
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Natalia Calanzani
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Jennifer Moodley
- Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Cancer Research Initiative, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- SAMRC Gynaecology Cancer Research Centre, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Greg P. Rubin
- Institute of Health and Society, Newcastle University, Sir James Spence Institute, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - Georgios Lyratzopoulos
- Epidemiology of Cancer Healthcare and Outcomes (ECHO) Research Group, Department of Behavioural Science and Health, University College London, London, United Kingdom
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