The SYMPTOM-upper gastrointestinal study: A mixed methods study exploring symptom appraisal and help-seeking in Australian upper gastrointestinal cancer patients

Objective

There is limited evidence on the development of pancreatic and oesophagogastric cancer, how patients decide to seek help and the factors impacting help‐seeking. Our study, the first in Australia, aimed to explore symptom appraisal and diagnostic pathways in these patients. A secondary aim was to examine the potential to recruit cancer patients through a cancer quality registry.

Methods

Patients diagnosed with pancreatic or oesophagogastric cancer were recruited through Monash University's Upper‐Gastrointestinal Cancer Registry. Data collected through general practitioners (GP) and patient questionnaires included symptoms and their onset, whereas patient interviews focused on the patient's decision‐making in seeking help from healthcare pracitioners. Data collection and analysis was informed by the Aarhus statement. Coding was inductive, and themes were mapped onto the Model of Pathways to Treatment.

Results

Between November 2018 and March 2020, 27 patient questionnaires and 13 phone interviews were completed. Prior to diagnosis, patients lacked awareness of pancreatic and oesophagogastric cancer symptoms, leading to the normalisation, dismissal and misattribution of the symptoms. Patients initially self‐managed symptoms, but worsening of symptoms and jaundice triggered help‐seeking. Competing priorities, beliefs about illnesses and difficulties accessing healthcare delayed help‐seeking.

Conclusion

Increased awareness of insidious pancreatic and oesophagogastric cancer symptoms in patients and general practitioners may prompt more urgent investigations and lead to earlier diagnosis.

Oesophageal cancer treatment patterns, timeliness of care and outcomes in the Loddon Mallee region of Victoria: A retrospective cohort study

INTRODUCTION

Few studies have investigated oesophageal cancer care in regional areas. This study aimed to describe treatment patterns for oesophageal cancer in a regional area, and to identify factors associated with radiotherapy utilisation, timeliness of care, and death.

METHODS

In a retrospective cohort study, medical records were reviewed to source data on all patients diagnosed with and/or treated for oesophageal cancer at two regional Victorian hospitals over July 2015-June 2018. Cox proportional hazards regression was employed to identify factors associated with time from diagnosis to death while binary logistic regression was used to identify factors associated with radiotherapy utilisation and treatment within 28 days of diagnosis - a time frame derived from the relevant optimal care pathway.

RESULTS

Of 95 patients, 72% had radiotherapy, 32% received any treatment within 28 days, and 78% died over a median time of nine months. Odds of not receiving radiotherapy were decreased (odds ratio [OR] = 0.26, 95% confidence interval [CI] = 0.08-0.87) for histology other than adenocarcinoma. Odds of timely care were increased for any palliative radiotherapy (OR = 3.47, 95% CI = 1.15-10.5) and decreased for older age (OR = 0.95, 95% CI = 0.91.0.999). Hazard of death was elevated for stage IV disease (hazard ratio [HR] = 2.73, 95% CI = 1.64-4.54) and reduced for radical intent (HR = 0.27, 95% CI = 0.15-0.48).

CONCLUSION

Nearly three-quarters of regional oesophageal cancer patients had radiotherapy while approximately one-third received any treatment within the recommended 28 days. Any palliative radiotherapy and younger age were associated with timely treatment. Future studies could further investigate factors related to timely oesophageal cancer care.

Augmenting cancer registry data with health survey data with no cases in common: the relationship between pre-diagnosis health behaviour and post-diagnosis survival in oesophageal cancer

Background

For epidemiological research, cancer registry datasets often need to be augmented with additional data. Data linkage is not feasible when there are no cases in common between data sets. We present a novel approach to augmenting cancer registry data by imputing pre-diagnosis health behaviour and estimating its relationship with post-diagnosis survival time.

Methods

Six measures of pre-diagnosis health behaviours (focussing on tobacco smoking, ‘at risk’ alcohol consumption, overweight and exercise) were imputed for 28,000 cancer registry data records of US oesophageal cancers using cold deck imputation from an unrelated health behaviour dataset. Each data point was imputed twice. This calibration allowed us to estimate the misclassification rate. We applied statistical correction for the misclassification to estimate the relative risk of dying within 1 year of diagnosis for each of the imputed behaviour variables. Subgroup analyses were conducted for adenocarcinoma and squamous cell carcinoma separately.

Results

Simulated survival data confirmed that accurate estimates of true relative risks could be retrieved for health behaviours with greater than 5% prevalence, although confidence intervals were wide. Applied to real datasets, the estimated relative risks were largely consistent with current knowledge. For example, tobacco smoking status 5 years prior to diagnosis was associated with an increased age-adjusted risk of all cause death within 1 year of diagnosis for oesophageal squamous cell carcinoma (RR = 1.99 95% CI 1.24,3.12) but not oesophageal adenocarcinoma RR = 1.61, 95% CI 0.79,2.57).

Conclusions

We have demonstrated a novel imputation-based algorithm for augmenting cancer registry data for epidemiological research which can be used when there are no cases in common between data sets. The algorithm allows investigation of research questions which could not be addressed through direct data linkage.

Using estimated probability of pre-diagnosis behavior as a predictor of cancer survival time: an example in esophageal cancer

Background

Information on the associations between pre-diagnosis health behavior and post-diagnosis survival time in esophageal cancer could assist in planning health services but can be difficult to obtain using established study designs. We postulated that, with a large data set, using estimated probability for a behavior as a predictor of survival times could provide useful insight as to the impact of actual behavior.

Methods

Data from a national health survey and logistic regression were used to calculate the probability of selected health behaviors from participant’s demographic characteristics for each esophageal cancer case within a large cancer registry data base. The associations between survival time and the probability of the health behaviors were investigated using Cox regression.

Results

Observed associations include: a 0.1 increase in the probability of smoking 1 year prior to diagnosis was detrimental to survival (Hazard Ratio (HR) 1.21, 95% CI 1.19,1.23); a 0.1 increase in the probability of hazardous alcohol consumption 10 years prior to diagnosis was associated with decreased survival in squamous cell cancer (HR 1.29, 95% CI 1.07, 1.56) but not adenocarcinoma (HR 1.08, 95% CI 0.94,1.25); a 0.1 increase in the probability of physical activity outside the workplace is protective (HR 0.83, 95% CI 0.81,0.84).

Conclusions

We conclude that probability for health behavior estimated from demographic characteristics can provide an initial assessment of the association between pre-diagnosis health behavior and post-diagnosis health outcomes, allowing some sharing of information across otherwise unrelated data collections.

Pattern of care for cancer of the oesophagus in a western population

BACKGROUND

Most oesophageal outcome research focuses on surgical treatment, despite most patients not undergoing surgery as they are unfit or have metastatic disease. Few studies have evaluated the patterns of care for all patients presenting with oesophageal cancer.

METHODS

All patients with oesophageal cancer, and high-grade dysplasia (HGD), presented at the South Australian state-wide upper gastrointestinal cancer multidisciplinary team from 2012 to 2015 were reviewed to determine the patterns of presentation and treatment.

RESULTS

A total of 375 patients were included. Diagnosis was adenocarcinoma in 69.6%, squamous cell carcinoma in 24.8% and HGD in 5.6%. The majority of patients presented with stages II and III disease (56.8%). A total of 51.5% were treated with curative intent, with 28.8% undergoing surgery and/or neoadjuvant therapy. Treatment was palliative in 48.5%, with chemoradiotherapy utilized in 20.8%. Disease stage and age impacted treatment intent. All patients with HGD received curative treatment versus 89.7%/63.8%/1% of patients with stage I/II and III/IV disease, respectively. A total of 56.9% of patients <80 years received curative treatment versus 25% of those >80 years old.

CONCLUSION

Whilst approximately half of patients underwent treatment with curative intent, only a minority underwent surgery. Future efforts to improve survival outcomes for oesophageal cancer should address patients who are unfit for surgery and those presenting with metastatic disease.

CD151 Gene and Protein Expression Provides Independent Prognostic Information for Patients with Adenocarcinoma of the Esophagus and Gastroesophageal Junction Treated by Esophagectomy

BACKGROUND

Esophageal and gastroesophageal junctional (GEJ) adenocarcinoma is one of the most fatal cancers and has the fastest rising incidence rate of all cancers. Identification of biomarkers is needed to tailor treatments to each patient's tumor biology and prognosis.

METHODS

Gene expression profiling was performed in a test cohort of 80 chemoradiotherapy (CRTx)-naïve patients with external validation in a separate cohort of 62 CRTx-naïve patients and 169 patients with advanced-stage disease treated with CRTx.

RESULTS

As a novel prognostic biomarker after external validation, CD151 showed promise. Patients exhibiting high levels of CD151 (≥median) had a longer median overall survival than patients with low CD151 tumor levels (median not reached vs. 30.9 months; p = 0.01). This effect persisted in a multivariable Cox-regression model with adjustment for tumor stage [adjusted hazard ratio (aHR), 0.33; 95 % confidence interval (CI), 0.14-0.78; p = 0.01] and was further corroborated through immunohistochemical analysis (aHR, 0.22; 95 % CI, 0.08-0.59; p = 0.003). This effect was not found in the separate cohort of CRTx-exposed patients.

CONCLUSION

Tumoral expression levels of CD151 may provide independent prognostic information not gained by conventional staging of patients with esophageal and GEJ adenocarcinoma treated by esophagectomy alone.

Clinical issues in oesophageal adenocarcinoma: could DNA copy number hold the key?

While not being considered a common cancer, since 1975 oesophageal adenocarcinoma (OAC) has had the fastest-rising incidence of any malignancy in Caucasian Western populations. In the absence of major improvements in treatment since this rise began, the number of deaths has also increased rapidly. In contrast, there have been significant advances in basic science in this period. One such advance is the discovery of DNA copy number aberrations (CNAs), and their potential role in carcinogenesis. The study of CNAs offers the potential to answer fundamental clinical questions in OAC, which in turn may lead to improved diagnosis, staging and treatment. This review outlines current clinical dilemmas in OAC, discusses the role that CNAs have been shown to play to date and highlights potential future applications.

Modeling the cost-effectiveness of strategies for treating esophageal adenocarcinoma and high-grade dysplasia

OBJECTIVE

This study aims to synthesize cost and health outcomes for current treatment pathways for esophageal adenocarcinoma and high-grade dysplasia (HGD) and to model comparative net clinical and economic benefits of alternative management scenarios.

METHODS

A decision-analytic model of real-world practices for esophageal adenocarcinoma treatment by tumor stage was constructed and validated. The model synthesized treatment probabilities, survival, quality of life, and resource use extracted from epidemiological datasets, published literature, and expert opinion. Comparative analyses between current practice and five hypothetical scenarios for modified treatment were undertaken.

RESULTS

Over 5 years, outcomes across T stage ranged from 4.06 quality-adjusted life-years and costs of $3,179 for HGD to 1.62 quality-adjusted life-years and costs of $50,226 for stage T4. Greater use of endoscopic mucosal resection for stage T1 and measures to reduce esophagectomy mortality to 0-3 % produced modest gains, whereas a 20 % reduction in the proportion of patients presenting at stage T3 produced large incremental net benefits of $4,971 (95 % interval, $1,560-8,368).

CONCLUSION

These findings support measures that promote earlier diagnosis, such as developing risk assessment processes or endoscopic surveillance of Barrett's esophagus. Incremental net monetary benefits for other strategies are relatively small in comparison to predicted gains from early detection strategies.

The influence of prediagnostic demographic and lifestyle factors on esophageal squamous cell carcinoma survival

Demographic and lifestyle factors, in particular tobacco smoking and alcohol, are well established causes of esophageal squamous cell carcinoma (ESCC); however, little is known about the effect of these factors on survival. We included all 301 patients with incident ESCC, recruited into a population-based case-control study of esophageal cancer in Australia. Detailed information about demographic and lifestyle factors was obtained at diagnosis, and deaths were identified using the National Death Index. Median follow-up for all-cause mortality was 6.4 years. Hazard ratios (HRs) and 95% confidence intervals (95% CI) were calculated from Cox proportional hazards models, adjusted for age, sex, pretreatment AJCC tumor stage, treatment and presence of comorbidities. Two hundred and thirteen patients (71%) died during follow-up. High lifetime alcohol consumption was independently associated with poor survival. Relative to life-long nondrinkers and those consuming<1 drink/week, the HRs for those with average consumption of 7-20 drinks/week or ≥21 drinks/week were 2.21 (95% CI=1.27-3.84) and 2.08 (95% CI=1.18-3.69), respectively. There was a suggestion of worse survival among current smokers (HR=1.42, 95% CI=0.89-2.28); however, the risk of early death was greatest among current smokers who reported regularly (≥7 drinks/week) consuming alcohol (HR=3.84, 95% CI=2.02-7.32). Other lifestyle factors putatively associated with risk of developing ESCC were not associated with survival. In addition to increasing disease risk, heavy alcohol consumption may be independently associated with worse survival among patients with ESCC. Future clinical follow-up studies should consider alcohol as a potential prognosticator, in addition to known clinicopathologic factors.