Delay by internists in obtaining diagnostic biopsies in patients with suspected cancer

Multidisciplinary care in the oncology setting: historical perspective and data from lung and gynecology multidisciplinary clinics

Multidisciplinary care refers to a practice in which physicians from multiple specialties attend to the same patient population. There are many advantages to the model, including reduced time to treatment, coordinated treatment plans, increased patient and physician satisfaction, and increased enrollment onto clinical trials. At Central Dupage Hospital, multidisciplinary clinics have been instituted in lung and gynecologic cancer. We describe the structure and operation of each clinic and highlight their considerable success in improving patient care.

Errors in cancer diagnosis: current understanding and future directions

PURPOSE

Errors in cancer diagnosis are likely the most harmful and expensive types of diagnostic errors. We reviewed the literature to understand the prevalence, origins, and prevention of errors in cancer diagnosis, focusing on common cancers for which early diagnosis offers clear benefit (melanoma and cancers of the breast, colon, and lung).

METHODS

We searched the Cochrane Library and PubMed from 1966 until April 2007 for publications that met our review criteria and manually searched references of key publications. Our search yielded 110 studies, of which nine were prospective studies and the remaining were retrospective studies.

RESULTS

Errors in cancer diagnosis were not uncommon in autopsy studies and were associated with significant harm and expense in malpractice claims. Literature on prevalence was scant. For each type of cancer, we classified preventable errors according to their origins in patient-physician encounters in the clinic setting, diagnostic test or procedure performance, pathologic confirmation of diagnosis, follow-up of patient or test result, or patient-related delays.

CONCLUSION

The literature reflects advanced knowledge of contributory factors and prevention for diagnostic errors related to the performance of procedures and imaging tests and emerging understanding of pathology errors. However, prospective studies are few, as are studies of diagnostic errors arising from the clinical encounter and patient follow-up. Future research should examine further the system and cognitive problems that lead to the many contributory factors we identified, and address interdisciplinary interventions to prevent errors in cancer diagnosis.

Le diagnostic des cancers solides dans un service de médecine interne: étude descriptive de 114 cas consécutifs

PURPOSE

A deterioration of the general condition, a prolonged fever or an unexplained inflammatory syndrome are frequent reasons for hospitalization in a internal medicine unit. In these situations, it is not rare to make a diagnosis of cancer.

PATIENTS AND METHODS

A descriptive study was carried out over a three years period (1st October 1999 to 30th September 2002) in an internal medicine unit. Every week, all patients in whom a cancer was diagnosed were enrolled in the study.

RESULTS

During this period, 165 patients were identified (3.8% of the in-patients). A histological proof was obtained in 114 patients. Digestive and bronchopulmonary cancers were the most frequent. The first signs were very varied but digestive disorders and ferriprive anaemia were the most frequent. The number of investigations necessary to diagnosis were weak (1.56 procedures) when a sign was identified but were high (5.12 procedures) when no information was provided by interview, clinical examination or usual biological tests.

CONCLUSION

Diagnosis of cancer is an usual situation in an internal medicine unit. Interview and clinical examination are essential in the diagnostic step. It could decrease the number of procedures. Internal unit services are fully concerned by the announcement of cancer.

Diagnosing cancer: changing patterns of care

We prospectively assessed 100 consecutive inpatient referrals made to the Medical Oncology Unit. The major end-point was the time to diagnostic biopsy. Referral trends and treatment outcomes were also recorded. Our results show that the referring units undertook the diagnostic process in the vast majority and the time to inpatient diagnostic biopsy has fallen from 10 to 4.6 days, compared with a similar study 13 years ago. This emphasizes the changing role of the oncologist in current day multidisciplinary cancer care.

Immunohistochemical Analysis of Metastatic Neoplasms of the Central Nervous System

Metastatic neoplasms to the central nervous system are often encountered in the practice of surgical neuropathology. It is not uncommon for patients with systemic malignancies to present to medical attention because of symptoms from a brain metastasis and for the tissue samples procured from these lesions to represent the first tissue available to study a malignancy from an unknown primary. In general surgical pathology, the evaluation of a metastatic neoplasm of unknown primary is a very complicated process, requiring knowledge of numerous different tumor types, reagents, and staining patterns. The past few years, however, have seen a remarkable refinement in the immunohistochemical tools at our disposal that now empower neuropathologists to take an active role in defining the relatively limited subset of neoplasms that commonly metastasize to the central nervous system. This information can direct imaging studies to find the primary tumor in a patient with an unknown primary, clarify the likely primary site of origin in patients who have small tumors in multiple sites without an obvious primary lesion, or establish lesions as late metastases of remote malignancies. Furthermore, specific treatments can begin and additional invasive procedures may be prevented if the neuropathologic evaluation of metastatic neoplasms provides information beyond the traditional diagnosis of "metastatic neoplasm." In this review, differential cytokeratins, adjuvant markers, and organ-specific antibodies are described and the immunohistochemical signatures of metastatic neoplasms that are commonly seen by neuropathologists are discussed.

Delay in diagnosis and its effect on outcome in head and neck cancer

We examined the records of two cohorts of patients who were seen from 1960 to 1999 with a diagnosis of squamous cell carcinoma (SCC) of the mouth and throat, one series being retrospective (n=400) and the other prospective (n=213) to find out about delays in diagnosis. The median delay in both cohorts was 3 months and the patients were responsible for the delay in most cases (n=319, 81% and n=160, 78%, respectively). Half the patients in each cohort had delayed diagnoses (n=217, 54% and n=119, 56%, respectively) and similar percentages (n=110, 53% and n=172, 47%) presented with advanced disease (stage III or IV). These were not the same patients for there was no correlation between delay and stage or survival. Logistic regression analysis showed that non-white race (p=0.01) and high-grade histology (p=0.002) predicted advanced disease. The proportion of patients presenting with advanced disease had not changed in 40 years despite public education. We suggest that some tumours may be silent and that initial symptoms do not reliably predict early disease.

Consultations for 'maladaptive denial of illness' in patients with cancer: psychiatric disorders that result in noncompliance

Patients who present with late stages of cancer often have complicated medical and psychiatric problems which are labeled as 'maladaptive delay or denial.' In some of these patients, psychiatric problems have either contributed to the delay in medical presentation for care or have interfered with treatment of the late stage cancer. The authors review some of the factors that contributed to delay and noncompliance in a series of patients with cancer who were evaluated by the psychiatric consultation service of a university hospital. Specifically, psychoses and cognitive impairment played a major role in delay and noncompliance. The authors discuss recommendations for management of such patients, and suggest that clinicians often benefit from the assistance of the psychiatric consultant as part of the treatment team. Multiple resources and multiple types of intervention are needed in order to help such patients negotiate the clinical environment.