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Zakkak N, Barclay ME, Swann R, McPhail S, Rubin G, Abel GA, Lyratzopoulos G. The presenting symptom signatures of incident cancer: evidence from the English 2018 National Cancer Diagnosis Audit. Br J Cancer 2024; 130:297-307. [PMID: 38057397 PMCID: PMC10803766 DOI: 10.1038/s41416-023-02507-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 10/27/2023] [Accepted: 11/13/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND Understanding relationships between presenting symptoms and subsequently diagnosed cancers can inform symptom awareness campaigns and investigation strategies. METHODS We used English National Cancer Diagnosis Audit 2018 data for 55,122 newly diagnosed patients, and examined the relative frequency of presenting symptoms by cancer site, and of cancer sites by presenting symptom. RESULTS Among 38 cancer sites (16 cancer groups), three classes were apparent: cancers with a dominant single presenting symptom (e.g. melanoma); cancers with diverse presenting symptoms (e.g. pancreatic); and cancers that are often asymptomatically detected (e.g. chronic lymphocytic leukaemia). Among 83 symptoms (13 symptom groups), two classes were apparent: symptoms chiefly relating to cancers of the same body system (e.g. certain respiratory symptoms mostly relating to respiratory cancers); and symptoms with a diverse cancer site case-mix (e.g. fatigue). The cancer site case-mix of certain symptoms varied by sex. CONCLUSION We detailed associations between presenting symptoms and cancer sites in a large, representative population-based sample of cancer patients. The findings can guide choice of symptoms for inclusion in awareness campaigns, and diagnostic investigation strategies post-presentation when cancer is suspected. They can inform the updating of clinical practice recommendations for specialist referral encompassing a broader range of cancer sites per symptom.
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Affiliation(s)
- N Zakkak
- Epidemiology of Cancer Healthcare and Outcomes (ECHO) Group, Department of Behavioural Science and Health, Institute of Epidemiology and Health Care, University College London, London, UK.
| | - M E Barclay
- Epidemiology of Cancer Healthcare and Outcomes (ECHO) Group, Department of Behavioural Science and Health, Institute of Epidemiology and Health Care, University College London, London, UK
| | - R Swann
- National Disease Registration Service, NHS England, London, UK
- Cancer Intelligence, Cancer Research UK, London, UK
| | - S McPhail
- National Disease Registration Service, NHS England, London, UK
| | - G Rubin
- Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, UK
| | - G A Abel
- Medical School, College of Medicine and Health, University of Exeter, St Luke's Campus, Heavitree Road, Exeter, London, UK
| | - G Lyratzopoulos
- Epidemiology of Cancer Healthcare and Outcomes (ECHO) Group, Department of Behavioural Science and Health, Institute of Epidemiology and Health Care, University College London, London, UK
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Barclay ME, Abel GA, Greenberg DC, Rous B, Lyratzopoulos G. Socio-demographic variation in stage at diagnosis of breast, bladder, colon, endometrial, lung, melanoma, prostate, rectal, renal and ovarian cancer in England and its population impact. Br J Cancer 2021; 124:1320-1329. [PMID: 33564123 PMCID: PMC8007585 DOI: 10.1038/s41416-021-01279-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 11/20/2020] [Accepted: 12/09/2020] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Stage at diagnosis strongly predicts cancer survival and understanding related inequalities could guide interventions. METHODS We analysed incident cases diagnosed with 10 solid tumours included in the UK government target of 75% of patients diagnosed in TNM stage I/II by 2028. We examined socio-demographic differences in diagnosis at stage III/IV vs. I/II. Multiple imputation was used for missing stage at diagnosis (9% of tumours). RESULTS Of the 202,001 cases, 57% were diagnosed in stage I/II (an absolute 18% 'gap' from the 75% target). The likelihood of diagnosis at stage III/IV increased in older age, though variably by cancer site, being strongest for prostate and endometrial cancer. Increasing level of deprivation was associated with advanced stage at diagnosis for all sites except lung and renal cancer. There were, inconsistent in direction, sex inequalities for four cancers. Eliminating socio-demographic inequalities would translate to 61% of patients with the 10 studied cancers being diagnosed at stage I/II, reducing the gap from target to 14%. CONCLUSIONS Potential elimination of socio-demographic inequalities in stage at diagnosis would make a substantial, though partial, contribution to achieving stage shift targets. Earlier diagnosis strategies should additionally focus on the whole population and not only the high-risk socio-demographic groups.
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Affiliation(s)
- M E Barclay
- The Healthcare Improvement Studies (THIS) Institute, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Epidemiology of Cancer Healthcare and Outcomes (ECHO) Research Group, Department of Behavioural Science and Health, University College London, London, UK
| | - G A Abel
- University of Exeter Medical School (Primary Care), Exeter, UK
| | - David C Greenberg
- National Cancer Registration and Analysis Service, Public Health England, London, UK
| | - B Rous
- National Cancer Registration and Analysis Service, Public Health England, London, UK
| | - G Lyratzopoulos
- The Healthcare Improvement Studies (THIS) Institute, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK.
- Epidemiology of Cancer Healthcare and Outcomes (ECHO) Research Group, Department of Behavioural Science and Health, University College London, London, UK.
- National Cancer Registration and Analysis Service, Public Health England, London, UK.
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Herbert A, Winters S, McPhail S, Elliss-Brookes L, Lyratzopoulos G, Abel GA. Population trends in emergency cancer diagnoses: The role of changing patient case-mix. Cancer Epidemiol 2019; 63:101574. [PMID: 31655434 PMCID: PMC6905147 DOI: 10.1016/j.canep.2019.101574] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 07/15/2019] [Accepted: 07/18/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Diagnosis of cancer through an emergency presentation is associated with worse clinical and patient experience outcomes. The proportion of patients with cancer who are diagnosed through emergency presentations has consequently been introduced as a routine cancer surveillance measure in England. Welcome reductions in this metric have been reported over more than a decade but whether reductions reflect true changes in how patients are diagnosed rather than the changing case-mix of incident cohorts in unknown. METHODS We analysed 'Routes to Diagnosis' data on cancer patients (2006-2015) and used logistic regression modelling to determine the contribution of changes in four case-mix variables (sex, age, deprivation, cancer site) to time-trends in emergency presentations. RESULTS Between 2006 and 2015 there was an absolute 4.7 percentage point reduction in emergency presentations (23.8%-19.2%). Changing distributions of the four case-mix variables explained 19.0% of this reduction, leaving 81.0% unexplained. Changes in cancer site case-mix alone explained 16.0% of the total reduction. CONCLUSION Changes in case-mix (particularly that of cancer sites) account for about a fifth of the overall reduction in emergency presentations. This would support the use of adjustment/standardisation of reported statistics to support their interpretation and help appreciate the influence of case-mix, particularly regarding cancer sites with changing incidence. However, most of the reduction in emergency presentations remains unaccounted for, and likely reflects genuine changes during the study period in how patients were being diagnosed.
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Affiliation(s)
- A Herbert
- MRC Integrative Epidemiology Unit Bristol Medical School University of Bristol Bristol UK; Epidemiology of Cancer and Healthcare Outcomes (ECHO) Group, Research Department of Behavioural Science and Health, University College London, 1-19 Torrington Place, London, UK
| | - S Winters
- National Cancer Registration and Analysis Service (NCRAS), Public Health England, 6th Floor, Wellington House, 135-155 Waterloo Road, London, UK
| | - S McPhail
- National Cancer Registration and Analysis Service (NCRAS), Public Health England, 6th Floor, Wellington House, 135-155 Waterloo Road, London, UK
| | - L Elliss-Brookes
- National Cancer Registration and Analysis Service (NCRAS), Public Health England, 6th Floor, Wellington House, 135-155 Waterloo Road, London, UK
| | - G Lyratzopoulos
- Epidemiology of Cancer and Healthcare Outcomes (ECHO) Group, Research Department of Behavioural Science and Health, University College London, 1-19 Torrington Place, London, UK; National Cancer Registration and Analysis Service (NCRAS), Public Health England, 6th Floor, Wellington House, 135-155 Waterloo Road, London, UK; Cambridge Centre for Health Services Research, University of Cambridge Institute of Public Health, Forvie Site, Cambridge, UK.
| | - G A Abel
- University of Exeter Medical School, Exeter, UK
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Zhou Y, Mendonca SC, Abel GA, Hamilton W, Walter FM, Johnson S, Shelton J, Elliss-Brookes L, McPhail S, Lyratzopoulos G. Variation in 'fast-track' referrals for suspected cancer by patient characteristic and cancer diagnosis: evidence from 670 000 patients with cancers of 35 different sites. Br J Cancer 2018; 118:24-31. [PMID: 29182609 PMCID: PMC5765227 DOI: 10.1038/bjc.2017.381] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 09/16/2017] [Accepted: 09/26/2017] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND In England, 'fast-track' (also known as 'two-week wait') general practitioner referrals for suspected cancer in symptomatic patients are used to shorten diagnostic intervals and are supported by clinical guidelines. However, the use of the fast-track pathway may vary for different patient groups. METHODS We examined data from 669 220 patients with 35 cancers diagnosed in 2006-2010 following either fast-track or 'routine' primary-to-secondary care referrals using 'Routes to Diagnosis' data. We estimated the proportion of fast-track referrals by sociodemographic characteristic and cancer site and used logistic regression to estimate respective crude and adjusted odds ratios. We additionally explored whether sociodemographic associations varied by cancer. RESULTS There were large variations in the odds of fast-track referral by cancer (P<0.001). Patients with testicular and breast cancer were most likely to have been diagnosed after a fast-track referral (adjusted odds ratios 2.73 and 2.35, respectively, using rectal cancer as reference); whereas patients with brain cancer and leukaemias least likely (adjusted odds ratios 0.05 and 0.09, respectively, for brain cancer and acute myeloid leukaemia). There were sex, age and deprivation differences in the odds of fast-track referral (P<0.013) that varied in their size and direction for patients with different cancers (P<0.001). For example, fast-track referrals were least likely in younger women with endometrial cancer and in older men with testicular cancer. CONCLUSIONS Fast-track referrals are less likely for cancers characterised by nonspecific presenting symptoms and patients belonging to low cancer incidence demographic groups. Interventions beyond clinical guidelines for 'alarm' symptoms are needed to improve diagnostic timeliness.
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Affiliation(s)
- Y Zhou
- Cambridge Centre for Health Services Research, Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, 2 Wort’s Causeway, Cambridge CB1 8RN, UK
| | - S C Mendonca
- Cambridge Centre for Health Services Research, Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, 2 Wort’s Causeway, Cambridge CB1 8RN, UK
| | - G A Abel
- University of Exeter Medical School (Primary Care), Smeall Building, St Luke’s Campus, Exeter EX1 2LU, UK
| | - W Hamilton
- University of Exeter Medical School (Primary Care), Smeall Building, St Luke’s Campus, Exeter EX1 2LU, UK
| | - F M Walter
- Cambridge Centre for Health Services Research, Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, 2 Wort’s Causeway, Cambridge CB1 8RN, UK
| | - S Johnson
- National Cancer Registration and Analysis Service, Public Health England Zone A, 2nd Floor, Skipton House, 80 London Road, London SE1 6LH, UK
| | - J Shelton
- Cancer Research UK, Angel Building 407 St John Street, London EC1V 4AD, UK
| | - L Elliss-Brookes
- National Cancer Registration and Analysis Service, Public Health England Zone A, 2nd Floor, Skipton House, 80 London Road, London SE1 6LH, UK
| | - S McPhail
- National Cancer Registration and Analysis Service, Public Health England Zone A, 2nd Floor, Skipton House, 80 London Road, London SE1 6LH, UK
| | - G Lyratzopoulos
- Cambridge Centre for Health Services Research, Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, 2 Wort’s Causeway, Cambridge CB1 8RN, UK
- National Cancer Registration and Analysis Service, Public Health England Zone A, 2nd Floor, Skipton House, 80 London Road, London SE1 6LH, UK
- Epidemiology of Cancer Healthcare and Outcomes (ECHO) Research Group, Department of Behavioural Science and Health, University College London, 1-19 Torrington Place, London WC1E 7HB, UK
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Mendonca SC, Abel GA, Saunders CL, Wardle J, Lyratzopoulos G. Pre-referral general practitioner consultations and subsequent experience of cancer care: evidence from the English Cancer Patient Experience Survey. Eur J Cancer Care (Engl) 2016; 25:478-90. [PMID: 26227343 PMCID: PMC4855626 DOI: 10.1111/ecc.12353] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2015] [Indexed: 12/11/2022]
Abstract
Prolonged diagnostic intervals may negatively affect the patient experience of subsequent cancer care, but evidence about this assertion is sparse. We analysed data from 73 462 respondents to two English Cancer Patient Experience Surveys to examine whether patients with three or more (3+) pre-referral consultations were more likely to report negative experiences of subsequent care compared with patients with one or two consultations in respect of 12 a priori selected survey questions. For each of 12 experience items, logistic regression models were used, adjusting for prior consultation category, cancer site, socio-demographic case-mix and response tendency (to capture potential variation in critical response tendencies between individuals). There was strong evidence (P < 0.01 for all) that patients with 3+ pre-referral consultations reported worse care experience for 10/12 questions, with adjusted odds ratios compared with patients with 1-2 consultations ranging from 1.10 (95% confidence intervals 1.03-1.17) to 1.68 (1.60-1.77), or between +1.8% and +10.6% greater percentage reporting a negative experience. Associations were stronger for processes involving primary as opposed to hospital care; and for evaluation than report items. Considering 1, 2, 3-4 and '5+' pre-referral consultations separately a 'dose-response' relationship was apparent. We conclude that there is a negative association between multiple pre-diagnostic consultations with a general practitioner and the experience of subsequent cancer care.
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Affiliation(s)
- S C Mendonca
- Cambridge Centre for Health Services Research, Institute of Public Health, University of Cambridge, Cambridge, UK
| | - G A Abel
- Cambridge Centre for Health Services Research, Institute of Public Health, University of Cambridge, Cambridge, UK
| | - C L Saunders
- Cambridge Centre for Health Services Research, Institute of Public Health, University of Cambridge, Cambridge, UK
- RAND Europe, Cambridge, UK
| | - J Wardle
- Department of Epidemiology & Public Health, Health Behaviour Research Centre, University College London, London, UK
| | - G Lyratzopoulos
- Cambridge Centre for Health Services Research, Institute of Public Health, University of Cambridge, Cambridge, UK
- Department of Epidemiology & Public Health, Health Behaviour Research Centre, University College London, London, UK
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Abel GA, Shelton J, Johnson S, Elliss-Brookes L, Lyratzopoulos G. Cancer-specific variation in emergency presentation by sex, age and deprivation across 27 common and rarer cancers. Br J Cancer 2015; 112 Suppl 1:S129-36. [PMID: 25734396 PMCID: PMC4385986 DOI: 10.1038/bjc.2015.52] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Although overall sociodemographic and cancer site variation in the risk of cancer diagnosis through emergency presentation has been previously described, relatively little is known about how this risk may vary differentially by sex, age and deprivation group between patients with a given cancer. METHODS Data from the Routes to Diagnosis project on 749,645 patients (2006-2010) with any of 27 cancers that can occur in either sex were analysed. Crude proportions and crude and adjusted odds ratios were calculated for emergency presentation, and interactions between sex, age and deprivation with cancer were examined. RESULTS The overall proportion of patients diagnosed through emergency presentation varied greatly by cancer. Compared with men, women were at greater risk for emergency presentation for bladder, brain, rectal, liver, stomach, colon and lung cancer (e.g., bladder cancer-specific odds ratio for women vs men, 1.50; 95% CI 1.39-1.60), whereas the opposite was true for oral/oropharyngeal cancer, lymphomas and melanoma (e.g., oropharyngeal cancer-specific odds ratio for women vs men, 0.49; 95% CI 0.32-0.73). Similarly, younger patients were at higher risk for emergency presentation for acute leukaemia, colon, stomach and oesophageal cancer (e.g., colon cancer-specific odds ratio in 35-44- vs 65-74-year-olds, 2.01; 95% CI 1.76-2.30) and older patients for laryngeal, melanoma, thyroid, oral and Hodgkin's lymphoma (e.g., melanoma specific odds ratio in 35-44- vs 65-74-year-olds, 0.20; 95% CI 0.12-0.33). Inequalities in the risk of emergency presentation by deprivation group were greatest for oral/oropharyngeal, anal, laryngeal and small intestine cancers. CONCLUSIONS Among patients with the same cancer, the risk for emergency presentation varies notably by sex, age and deprivation group. The findings suggest that, beyond tumour biology, diagnosis through an emergency route may be associated both with psychosocial processes, which can delay seeking of medical help, and with difficulties in suspecting the diagnosis of cancer after presentation.
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Affiliation(s)
- G A Abel
- Cambridge Centre for Health Services Research, Department of Public Health and Primary Care, Institute of Public Health, Forvie Site, Robinson Way, Cambridge CB2 0SR, UK
| | - J Shelton
- Care Quality Commission, Finsbury Tower, 103–105 Bunhill Row, London EC1Y 8TG, UK
- National Cancer Intelligence Network (NCIN), Public Health England, 5th Floor, Wellington House, 135-155 Waterloo Road, London SE1 8UG, UK
| | - S Johnson
- National Cancer Intelligence Network (NCIN), Public Health England, 5th Floor, Wellington House, 135-155 Waterloo Road, London SE1 8UG, UK
| | - L Elliss-Brookes
- National Cancer Intelligence Network (NCIN), Public Health England, 5th Floor, Wellington House, 135-155 Waterloo Road, London SE1 8UG, UK
| | - G Lyratzopoulos
- Cambridge Centre for Health Services Research, Department of Public Health and Primary Care, Institute of Public Health, Forvie Site, Robinson Way, Cambridge CB2 0SR, UK
- National Cancer Intelligence Network (NCIN), Public Health England, 5th Floor, Wellington House, 135-155 Waterloo Road, London SE1 8UG, UK
- Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London WC1E 6BT, UK
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Rutherford MJ, Abel GA, Greenberg DC, Lambert PC, Lyratzopoulos G. The impact of eliminating age inequalities in stage at diagnosis on breast cancer survival for older women. Br J Cancer 2015; 112 Suppl 1:S124-8. [PMID: 25734394 PMCID: PMC4385985 DOI: 10.1038/bjc.2015.51] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Older women with breast cancer have poorer relative survival outcomes, but whether achieving earlier stage at diagnosis would translate to substantial reductions in mortality is uncertain. METHODS We analysed data on East of England women with breast cancer (2006-2010) aged 70+ years. We estimated survival for different stage-deprivation-age group strata using both the observed and a hypothetical stage distribution (assuming that all women aged 75+ years acquired the stage distribution of those aged 70-74 years). We subsequently estimated deaths that could be postponed beyond 5 years from diagnosis if women aged 75+ years had the hypothetical stage distribution. We projected findings to the English population using appropriate age and socioeconomic group weights. RESULTS For a typically sized annual cohort in the East of England, 27 deaths in women with breast cancer aged 75+ years can be postponed within 5 years from diagnosis if their stage distribution matched that of the women aged 70-74 years (4.8% of all 566 deaths within 5 years post diagnosis in this population). Under assumptions, we estimate that the respective number for England would be 280 deaths (5.0% of all deaths within 5 years post diagnosis in this population). CONCLUSIONS The findings support ongoing development of targeted campaigns aimed at encouraging prompt presentation in older women.
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MESH Headings
- Age Factors
- Aged
- Aged, 80 and over
- Breast Neoplasms/diagnosis
- Breast Neoplasms/mortality
- Breast Neoplasms/pathology
- Carcinoma, Ductal, Breast/diagnosis
- Carcinoma, Ductal, Breast/mortality
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Lobular/diagnosis
- Carcinoma, Lobular/mortality
- Carcinoma, Lobular/pathology
- Cohort Studies
- England
- Female
- Health Status Disparities
- Healthcare Disparities
- Humans
- Socioeconomic Factors
- Survival Rate
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Affiliation(s)
- M J Rutherford
- Department of Health Sciences, University of Leicester, Leicester LE1 7RH UK
| | - G A Abel
- Cambridge Centre for Health Services Research, Department of Public Health and Primary Care, University of Cambridge, Cambridge CB2 0SR, UK
| | - D C Greenberg
- Cambridge Centre for Health Services Research, Department of Public Health and Primary Care, University of Cambridge, Cambridge CB2 0SR, UK
- National Cancer Registration Service, Public Health England, Eastern Office, Cambridge CB22 3AD, UK
| | - P C Lambert
- Department of Health Sciences, University of Leicester, Leicester LE1 7RH UK
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stocholm SE-171 77, Sweden
| | - G Lyratzopoulos
- Cambridge Centre for Health Services Research, Department of Public Health and Primary Care, University of Cambridge, Cambridge CB2 0SR, UK
- Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, UCL, 1-19 Torrington Place, London WC1E 6BT, UK
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Rutherford MJ, Ironmonger L, Ormiston-Smith N, Abel GA, Greenberg DC, Lyratzopoulos G, Lambert PC. Estimating the potential survival gains by eliminating socioeconomic and sex inequalities in stage at diagnosis of melanoma. Br J Cancer 2015; 112 Suppl 1:S116-23. [PMID: 25734390 PMCID: PMC4385984 DOI: 10.1038/bjc.2015.50] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Although inequalities in cancer survival are thought to reflect inequalities in stage at diagnosis, little evidence exists about the size of potential survival gains from eliminating inequalities in stage at diagnosis. METHODS We used data on patients diagnosed with malignant melanoma in the East of England (2006-2010) to estimate the number of deaths that could be postponed by completely eliminating socioeconomic and sex differences in stage at diagnosis after fitting a flexible parametric excess mortality model. RESULTS Stage was a strong predictor of survival. There were pronounced socioeconomic and sex inequalities in the proportion of patients diagnosed at stages III-IV (12 and 8% for least deprived men and women and 25 and 18% for most deprived men and women, respectively). For an annual cohort of 1025 incident cases in the East of England, eliminating sex and deprivation differences in stage at diagnosis would postpone approximately 24 deaths to beyond 5 years from diagnosis. Using appropriate weighting, the equivalent estimate for England would be around 215 deaths, representing 11% of all deaths observed within 5 years from diagnosis in this population. CONCLUSIONS Reducing socioeconomic and sex inequalities in stage at diagnosis would result in substantial reductions in deaths within 5 years of a melanoma diagnosis.
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Affiliation(s)
- M J Rutherford
- Department of Health Sciences, University of Leicester, Leicester LE1 7RH, UK
| | - L Ironmonger
- Statistical Information Team, Cancer Research UK, Angel Building, 407 St John Street, London EC1V 4AD, UK
| | - N Ormiston-Smith
- Statistical Information Team, Cancer Research UK, Angel Building, 407 St John Street, London EC1V 4AD, UK
| | - G A Abel
- Cambridge Centre for Health Services Research, Institute of Public Health, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - D C Greenberg
- Cambridge Centre for Health Services Research, Institute of Public Health, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- National Cancer Registration Service, Public Health England, Eastern Office, Cambridge CB22 3AD, UK
| | - G Lyratzopoulos
- Cambridge Centre for Health Services Research, Institute of Public Health, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Health Behaviour Research Centre, Department of Epedimiology and Public Health, University College London, 1-19 Torrington Place, London WC1E 6BT, UK
| | - P C Lambert
- Department of Health Sciences, University of Leicester, Leicester LE1 7RH, UK
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm SE-171 77, Sweden
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Lyratzopoulos G, Saunders CL, Abel GA, McPhail S, Neal RD, Wardle J, Rubin GP. The relative length of the patient and the primary care interval in patients with 28 common and rarer cancers. Br J Cancer 2015; 112 Suppl 1:S35-40. [PMID: 25734380 PMCID: PMC4385974 DOI: 10.1038/bjc.2015.40] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Appreciating variation in the length of pre- or post-presentation diagnostic intervals can help prioritise early diagnosis interventions with either a community or a primary care focus. METHODS We analysed data from the first English National Audit of Cancer Diagnosis in Primary Care on 10 953 patients with any of 28 cancers. We calculated summary statistics for the length of the patient and the primary care interval and their ratio, by cancer site. RESULTS Interval lengths varied greatly by cancer. Laryngeal and oropharyngeal cancers had the longest median patient intervals, whereas renal and bladder cancer had the shortest (34.5 and 30 compared with 3 and 2 days, respectively). Multiple myeloma and gallbladder cancer had the longest median primary care intervals, and melanoma and breast cancer had the shortest (20.5 and 20 compared with 0 and 0 days, respectively). Mean patient intervals were longer than primary care intervals for most (18 of 28) cancers, and notably so (two- to five-fold greater) for 10 cancers (breast, melanoma, testicular, vulval, cervical, endometrial, oropharyngeal, laryngeal, ovarian and thyroid). CONCLUSIONS The findings support the continuing development and evaluation of public health interventions aimed at shortening patient intervals, particularly for cancers with long patient interval and/or high patient interval over primary care interval ratio.
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Affiliation(s)
- G Lyratzopoulos
- Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London WC1E 6BT, UK
- Cambridge Centre for Health Services Research, Department of Public Health and Primary Care, University of Cambridge, Cambridge CB2 0SR, UK
| | - C L Saunders
- Cambridge Centre for Health Services Research, Department of Public Health and Primary Care, University of Cambridge, Cambridge CB2 0SR, UK
| | - G A Abel
- Cambridge Centre for Health Services Research, Department of Public Health and Primary Care, University of Cambridge, Cambridge CB2 0SR, UK
| | - S McPhail
- National Cancer Intelligence Network (NCIN), Public Health England, 5th Floor, Wellington House, 135-155 Waterloo Road, London SE1 8UG, UK
| | - R D Neal
- North Wales Centre for Primary Care Research, College of Health and Behavioural Sciences, Bangor University, Gwenfro Unit 5, Wrexham Technology Park, Wrexham LL13 7YP, UK
| | - J Wardle
- Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London WC1E 6BT, UK
| | - G P Rubin
- Wolfson Research Institute, School of Medicine and Health, University of Durham, Queen's Campus, University Boulevard, Stockton-on-Tees TS17 6BH, UK
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Rubin GP, Saunders CL, Abel GA, McPhail S, Lyratzopoulos G, Neal RD. Impact of investigations in general practice on timeliness of referral for patients subsequently diagnosed with cancer: analysis of national primary care audit data. Br J Cancer 2015; 112:676-87. [PMID: 25602963 PMCID: PMC4333492 DOI: 10.1038/bjc.2014.634] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Revised: 11/07/2014] [Accepted: 12/01/2014] [Indexed: 01/07/2023] Open
Abstract
Background: For patients with symptoms of possible cancer who do not fulfil the criteria for urgent referral, initial investigation in primary care has been advocated in the United Kingdom and supported by additional resources. The consequence of this strategy for the timeliness of diagnosis is unknown. Methods: We analysed data from the English National Audit of Cancer Diagnosis in Primary Care on patients with lung (1494), colorectal (2111), stomach (246), oesophagus (513), pancreas (327), and ovarian (345) cancer relating to the ordering of investigations by the General Practitioner and their nature. Presenting symptoms were categorised according to National Institute for Health and Care Excellence (NICE) guidance on referral for suspected cancer. We used linear regression to estimate the mean difference in primary-care interval by cancer, after adjustment for age, gender, and the symptomatic presentation category. Results: Primary-care investigations were undertaken in 3198/5036 (64%) of cases. The median primary-care interval was 16 days (IQR 5–45) for patients undergoing investigation and 0 days (IQR 0–10) for those not investigated. Among patients whose symptoms mandated urgent referral to secondary care according to NICE guidelines, between 37% (oesophagus) and 75% (pancreas) were first investigated in primary care. In multivariable linear regression analyses stratified by cancer site, adjustment for age, sex, and NICE referral category explained little of the observed prolongation associated with investigation. Interpretation: For six specified cancers, investigation in primary care was associated with later referral for specialist assessment. This effect was independent of the nature of symptoms. Some patients for whom urgent referral is mandated by NICE guidance are nevertheless investigated before referral. Reducing the intervals between test order, test performance, and reporting can help reduce the prolongation of primary-care intervals associated with investigation use. Alternative models of assessment should be considered.
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Affiliation(s)
- G P Rubin
- Evaluation, Research and Development Unit, School of Medicine, Pharmacy and Health, Wolfson Research Institute, University of Durham, Queen's Campus, University Boulevard, Stockton-on-Tees TS17 6BH, UK
| | - C L Saunders
- Department of Public Health and Primary Care, Cambridge Centre for Health Services Research, University of Cambridge, Cambridge CB2 0SR, UK
| | - G A Abel
- Department of Public Health and Primary Care, Cambridge Centre for Health Services Research, University of Cambridge, Cambridge CB2 0SR, UK
| | - S McPhail
- National Cancer Intelligence Network (NCIN), Public Health England, 5th Floor, Wellington House, 135-155 Waterloo Road, London SE1 8UG, UK
| | - G Lyratzopoulos
- Department of Public Health and Primary Care, Cambridge Centre for Health Services Research, University of Cambridge, Cambridge CB2 0SR, UK
| | - R D Neal
- North Wales Centre for Primary Care Research, College of Health & Behavioural Sciences, Bangor University, Gwenfro Unit 5, Wrexham Technology Park, Wrexham LL13 7YP, UK
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Saunders CL, Abel GA, Lyratzopoulos G. Inequalities in reported cancer patient experience by socio-demographic characteristic and cancer site: evidence from respondents to the English Cancer Patient Experience Survey. Eur J Cancer Care (Engl) 2014; 24:85-98. [PMID: 25327713 PMCID: PMC4309492 DOI: 10.1111/ecc.12267] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2014] [Indexed: 11/30/2022]
Abstract
Patient experience is a critical dimension of cancer care quality. Understanding variation in experience among patients with different cancers and characteristics is an important first step for designing targeted improvement interventions. We analysed data from the 2011/2012 English Cancer Patient Experience Survey (n = 69,086) using logistic regression to explore inequalities in care experience across 64 survey questions. We additionally calculated a summary measure of variation in patient experience by cancer, and explored inequalities between patients with cancers treated by the same specialist teams. We found that younger and very old, ethnic minority patients and women consistently reported worse experiences across questions. Patients with small intestine/rarer lower gastrointestinal, multiple myeloma and hepatobiliary cancers were most likely to report negative experiences whereas patients with breast, melanoma and testicular cancer were least likely (top-to-bottom odds ratio = 1.91, P < 0.0001). There were also inequalities in experience among patients with cancers treated by the same specialty for five of nine services (P < 0.0001). Specifically, patients with ovarian, multiple myeloma, anal, hepatobiliary and renal cancer reported notably worse experiences than patients with other gynaecological, haematological, gastrointestinal and urological malignancies respectively. Initiatives to improve cancer patient experience across oncology services may be suitably targeted on patients at higher risk of poorer experience.
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Affiliation(s)
- C L Saunders
- Cambridge Centre for Health Services Research, University of Cambridge, Cambridge, UK
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12
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Payne RA, Avery AJ, Duerden M, Saunders CL, Simpson CR, Abel GA. Prevalence of polypharmacy in a Scottish primary care population. Eur J Clin Pharmacol 2014; 70:575-81. [PMID: 24487416 DOI: 10.1007/s00228-013-1639-9] [Citation(s) in RCA: 126] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Accepted: 12/29/2013] [Indexed: 10/25/2022]
Abstract
PURPOSE Polypharmacy-the use of multiple medications by a single patient-is an important issue associated with various adverse clinical outcomes and rising costs. It is also a topic rarely addressed by clinical guidelines. We used routine Scottish health records to address the lack of data on the prevalence of polypharmacy in the broader, adult primary care population, particularly in relation to long-term conditions. METHODS We conducted a cross-sectional analysis of adult electronic primary healthcare records and used linear regression models to examine the association between the number of medicines prescribed regularly and both multimorbidity and specific clinical conditions, adjusting for age, gender and socioeconomic deprivation. RESULTS Overall, 16.9 % of the adults assessed were receiving four to nine medications, and 4.6 % were receiving ten or more medications, increasing with age (28.6 and 7.4 %, respectively, in those aged 60-69 years; 51.8 and 18.6 %, respectively, in those aged ≥ 80 years), but relatively unaffected by gender or deprivation. Of those patients with two clinical conditions, 20.8 % were receiving four to nine medications, and 1.1 % were receiving ten or more medications; in those patients with six or more comorbidities, these values were 47.7 and 41.7 %, respectively. The number of medications varied considerably between clinical conditions, with cardiovascular conditions associated with the greatest number of additional medications. The accumulation of additional medicines was less with concordant conditions. CONCLUSIONS Polypharmacy is common in UK primary care. The main factor associated with this is multimorbidity, although considerable variation exists between different conditions. The impact of clinical conditions on the number of medicines is generally less in the presence of co-existing concordant conditions.
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Affiliation(s)
- R A Payne
- Cambridge Centre for Health Services Research, Institute of Public Health, University of Cambridge, Forvie Site, Robinson Way, Cambridge, CB2 0SR, UK,
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13
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Saunders CL, Abel GA, El Turabi A, Ahmed F, Lyratzopoulos G. Accuracy of routinely recorded ethnic group information compared with self-reported ethnicity: evidence from the English Cancer Patient Experience survey. BMJ Open 2013; 3:bmjopen-2013-002882. [PMID: 23811171 PMCID: PMC3696860 DOI: 10.1136/bmjopen-2013-002882] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To describe the accuracy of ethnicity coding in contemporary National Health Service (NHS) hospital records compared with the 'gold standard' of self-reported ethnicity. DESIGN Secondary analysis of data from a cross-sectional survey (2011). SETTING All NHS hospitals in England providing cancer treatment. PARTICIPANTS 58 721 patients with cancer for whom ethnicity information (Office for National Statistics 2001 16-group classification) was available from self-reports (considered to represent the 'gold standard') and their hospital record. METHODS We calculated the sensitivity and positive predictive value (PPV) of hospital record ethnicity. Further, we used a logistic regression model to explore independent predictors of discordance between recorded and self-reported ethnicity. RESULTS Overall, 4.9% (4.7-5.1%) of people had their self-reported ethnic group incorrectly recorded in their hospital records. Recorded White British ethnicity had high sensitivity (97.8% (97.7-98.0%)) and PPV (98.1% (98.0-98.2%)) for self-reported White British ethnicity. Recorded ethnicity information for the 15 other ethnic groups was substantially less accurate with 41.2% (39.7-42.7%) incorrect. Recorded 'Mixed' ethnicity had low sensitivity (12-31%) and PPVs (12-42%). Recorded 'Indian', 'Chinese', 'Black-Caribbean' and 'Black African' ethnic groups had intermediate levels of sensitivity (65-80%) and PPV (80-89%, respectively). In multivariable analysis, belonging to an ethnic minority group was the only independent predictor of discordant ethnicity information. There was strong evidence that the degree of discordance of ethnicity information varied substantially between different hospitals (p<0.0001). DISCUSSION Current levels of accuracy of ethnicity information in NHS hospital records support valid profiling of White/non-White ethnic differences. However, profiling of ethnic differences in process or outcome measures for specific minority groups may contain a substantial and variable degree of misclassification error. These considerations should be taken into account when interpreting ethnic variation audits based on routine data and inform initiatives aimed at improving the accuracy of ethnicity information in hospital records.
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Affiliation(s)
- C L Saunders
- Cambridge Centre for Health Services Research, University of Cambridge, Institute of Public Health, Cambridge, UK
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14
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Rutherford MJ, Hinchliffe SR, Abel GA, Lyratzopoulos G, Lambert PC, Greenberg DC. How much of the deprivation gap in cancer survival can be explained by variation in stage at diagnosis: an example from breast cancer in the East of England. Int J Cancer 2013; 133:2192-200. [PMID: 23595777 DOI: 10.1002/ijc.28221] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Accepted: 04/11/2013] [Indexed: 12/12/2022]
Abstract
Socioeconomic differences in cancer patient survival exist in many countries and across cancer sites. In our article, we estimated the number of deaths in women with breast cancer that could be avoided within 5 years from diagnosis if it were possible to eliminate socioeconomic differences in stage at diagnosis. We analysed data on East of England women with breast cancer (2006-2010). We estimated survival for different stage-age-deprivation strata using both the observed and a hypothetical stage distribution (assuming all women acquired the stage distribution of the most affluent women). Data were analysed on 20,738 women with complete stage information (92%). Affluent women were less likely to be diagnosed in advanced stage. Relative survival decreased with increasing level of deprivation. Eliminating differences in stage at diagnosis could be expected to nearly eliminate differences in relative survival for women in deprivation groups 3 and 4, but would only approximately halve the difference in relative survival for women in the most deprived group (5). This means, for a typical cohort of women diagnosed in a calendar year with breast cancer, eliminating deprivation differences in stage at diagnosis would prevent ∼40 deaths in the East of England from occurring within 5 years from diagnosis. Using appropriate weighting we estimated the respective number of avoidable deaths for the whole of England to be ∼450. The findings suggest that policies aimed at reducing inequalities in stage at diagnosis between women with breast cancer are important to reduce inequalities in breast cancer survival.
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Affiliation(s)
- M J Rutherford
- Department of Health Sciences, University of Leicester, Leicester, United Kingdom.
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15
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Lyratzopoulos G, Abel GA, McPhail S, Neal RD, Rubin GP. Measures of promptness of cancer diagnosis in primary care: secondary analysis of national audit data on patients with 18 common and rarer cancers. Br J Cancer 2013; 108:686-90. [PMID: 23392082 PMCID: PMC3593564 DOI: 10.1038/bjc.2013.1] [Citation(s) in RCA: 111] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Revised: 12/05/2012] [Accepted: 12/16/2012] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Evidence is needed about the promptness of cancer diagnosis and associations between its measures. METHODS We analysed data from the National Audit of Cancer Diagnosis in Primary Care 2009-10 exploring the association between the interval from first symptomatic presentation to specialist referral (the primary care interval, or 'interval' hereafter) and the number of pre-referral consultations. RESULTS Among 13,035 patients with any of 18 different cancers, most (82%) were referred after 1 (58%) or 2 (25%) consultations (median intervals 0 and 15 days, respectively) while 9%, 4% and 5% patients required 3, 4 or 5+ consultations (median intervals 34, 47 and 97 days, respectively) (Spearman's r=0.70). The association was at least moderate for any cancer (Spearman's r range: 0.55 (prostate)-0.77 (brain)). Patients with cancers with a higher proportion of three or more pre-referral consultations typically also had longer median intervals (e.g., multiple myeloma) and vice versa (e.g., breast cancer). CONCLUSION The number of pre-referral consultations has construct validity as a measure of the primary care interval. Developing interventions to reduce the number of pre-referral consultations can help improve the timeliness of cancer diagnosis, and constitutes a priority for early diagnosis initiatives and research.
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Affiliation(s)
- G Lyratzopoulos
- Cambridge Centre for Health Services Research, Department of Public Health and Primary Care, University of Cambridge, Forvie Site, Robinson Way, Cambridge CB2 0SR, UK.
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16
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Lyratzopoulos G, Abel GA, Brown CH, Rous BA, Vernon SA, Roland M, Greenberg DC. Socio-demographic inequalities in stage of cancer diagnosis: evidence from patients with female breast, lung, colon, rectal, prostate, renal, bladder, melanoma, ovarian and endometrial cancer. Ann Oncol 2012; 24:843-50. [PMID: 23149571 PMCID: PMC3574550 DOI: 10.1093/annonc/mds526] [Citation(s) in RCA: 111] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Understanding socio-demographic inequalities in stage at diagnosis can inform priorities for cancer control. PATIENTS AND METHODS We analysed data on the stage at diagnosis of East of England patients diagnosed with any of 10 common cancers, 2006-2010. Stage information was available on 88 657 of 98 942 tumours (89.6%). RESULTS Substantial socio-demographic inequalities in advanced stage at diagnosis (i.e. stage III/IV) existed for seven cancers, but their magnitude and direction varied greatly by cancer: advanced stage at diagnosis was more likely for older patients with melanoma but less likely for older patients with lung cancer [odds ratios for 75-79 versus 65-69 1.60 (1.38-1.86) and 0.83 (0.77-0.89), respectively]. Deprived patients were more likely to be diagnosed in advanced stage for melanoma, prostate, endometrial and (female) breast cancer: odds ratios (most versus least deprived quintile) from 2.24 (1.66-3.03) for melanoma to 1.31 (1.15-1.49) for breast cancer. In England, elimination of socio-demographic inequalities in stage at diagnosis could decrease the number of patients with cancer diagnosed in advanced stage by ∼5600 annually. CONCLUSIONS There are substantial socio-demographic inequalities in stage at diagnosis for most cancers. Earlier detection interventions and policies can be targeted on patients at higher risk of advanced stage diagnosis.
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Affiliation(s)
- G Lyratzopoulos
- Cambridge Centre for Health Services Research, Institute of Public Health, University of Cambridge, Cambridge, UK.
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17
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Martins Y, Lederman RI, Lowenstein CL, Joffe S, Neville BA, Hastings BT, Abel GA. Increasing response rates from physicians in oncology research: a structured literature review and data from a recent physician survey. Br J Cancer 2012; 106:1021-6. [PMID: 22374464 PMCID: PMC3304407 DOI: 10.1038/bjc.2012.28] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2011] [Revised: 01/16/2012] [Accepted: 01/25/2012] [Indexed: 11/30/2022] Open
Abstract
Although the physician survey has become an important tool for oncology-focused health services research, such surveys often achieve low response rates. This mini-review reports the results of a structured review of the literature relating to increasing response rates for physician surveys, as well as our own experience from a survey of physicians as to their referral practices for suspected haematologic malignancy in the United States. PubMed and PsychINFO databases were used to identify methodological articles assessing factors that influence response rates for physician surveys; the results were tabulated and reviewed for trends. We also analysed the impact of a follow-up telephone call by a physician investigator to initial non-responders in our own mailed physician survey, comparing the characteristics of those who responded before vs after the call. The systematic review suggested that monetary incentives and paper (vs web or email) surveys increase response rates. In our own survey, follow-up telephone calls increased the response rate from 43.7% to 70.5%, with little discernible difference in the characteristics of early vs later responders. We conclude that in addition to monetary incentives and paper surveys, physician-to-physician follow-up telephone calls are an effective method to increase response rates in oncology-focused physician surveys.
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Affiliation(s)
- Y Martins
- Center for Population Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
- Department of Medicine, Children's Hospital Boston, Boston, MA, USA
| | - R I Lederman
- Center for Population Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
| | - C L Lowenstein
- Center for Population Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
| | - S Joffe
- Center for Population Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
- Department of Medicine, Children's Hospital Boston, Boston, MA, USA
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - B A Neville
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Dana 1108, Boston, MA 02215, USA
| | - B T Hastings
- Center for Population Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Dana 1108, Boston, MA 02215, USA
| | - G A Abel
- Center for Population Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Dana 1108, Boston, MA 02215, USA
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18
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Abel GA, Neville BA, Weeks JC, Stone RM. Assessment of performance measures for patients with the myelodysplastic syndrome (MDS) in the United States. J Clin Oncol 2010. [DOI: 10.1200/jco.2010.28.15_suppl.6002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Abstract
OBJECTIVE In the United States, the Food and Drug Administration (FDA) requires that all direct-to-consumer advertising (DTCA) contain both an accurate statement of a medication's effects ('truth') and an even-handed discussion of its benefits and risks/adverse effects ('fair balance'). DTCA for medications to treat rare diseases such as bleeding disorders is unlikely to be given high priority for FDA review. METHODS We reviewed all DTCA for bleeding disorder products appearing in the patient-directed magazine HemeAware from January 2004 to June 2006. We categorized the information presented in each advertisement as benefit, risk/adverse effect, or neither, and assessed the amount of text and type size devoted to each. We also assessed the readability of each type of text using the Flesch Reading Ease Score (FRES, where a score of >or=65 is considered of average readability), and assessed the accuracy of the advertising claims utilizing a panel of five bleeding disorder experts. RESULTS A total of 39 unique advertisements for 12 products were found. On average, approximately twice the amount of text was devoted to benefits as compared with risks/adverse effects, and the latter was more difficult to read [FRES of 32.0 for benefits vs. 20.5 for risks/adverse effects, a difference of 11.5 (95% CI: 4.5-18.5)]. Only about two-thirds of the advertising claims were considered by a majority of the experts to be based on at least low-quality evidence. CONCLUSION As measured by our methods, print DTCA for bleeding disorders may not reach the FDA's standards of truth and fair balance.
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Affiliation(s)
- G A Abel
- Center for Outcomes and Policy Research, Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA 02115, USA.
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20
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Van Bennekom CM, Abel GA, Stone RM, Anderson TE, Kaufman DW. Classification of myelodysplastic syndrome in a national registry of recently-diagnosed patients—the Patient Registries at Slone: MDS. J Clin Oncol 2008. [DOI: 10.1200/jco.2008.26.15_suppl.6628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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21
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Abel GA, Hevelone ND, Burstein HJ, Weeks JC. Cancer-related direct-to-consumer advertising: awareness, perceived impact, and associated patient and provider behavior. J Clin Oncol 2008. [DOI: 10.1200/jco.2008.26.15_suppl.6631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Abel GA, Bertrand KA, Earle CC, Laden F. Outcomes for hematologic malignancies in the Nurses’ Health Study (NHS) as compared to the Surveillance, Epidemiology, and End Results (SEER) program. J Clin Oncol 2007. [DOI: 10.1200/jco.2007.25.18_suppl.6599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
6599 Background: Health literacy, often defined as the degree to which an individual can obtain and understand information needed to make appropriate health decisions, may lead to a decreased incidence and improved mortality for some cancers by promoting risk factor modification and adherence to treatment. As a result, nurses, who presumably possess a higher level of health literacy and access to care than the general population, might be expected to manifest a lower incidence of and better survival for the hematologic malignancies. Methods: We assessed the incidence, all-cause, and cause-specific mortality for Hodgkin's disease (HD), non-Hodgkin's lymphoma (NHL), multiple myeloma (MM) and chronic lymphocytic leukemia (CLL) in the NHS, an ongoing cohort study of 121,700 female registered nurses aged 30–55 years at entry who have been followed for 30 years. We compared these outcomes to those in the SEER program of the National Cancer Institute, matching for age and race. Results: In over 2.5 million person-years, the incidence of HD in the NHS was the same as in SEER. The incidence of NHL, CLL and MM was slightly increased. All-cause mortality was better in the NHS when compared to SEER for HD (HR= 0.62, 95% CI: [0.38, 1.0]) and NHL (HR= 0.81, 95% CI: [0.71, 0.91]). There were no differences in cause-specific mortality, except for MM, which was worse in the NHS (HR= 1.27, 95% CI: [1.07, 1.52]). Conclusion: The incidence of hematologic malignancy is not reduced in nurses, possibly because preventable risk factors for these cancers have yet to be elucidated. To the contrary, the slight increase in incidence for NHL, MM and CLL may be due to higher levels of overall health vigilance and/or occupational exposures. The fact that cancer-related mortality is similar for nurses as compared to age and race-matched SEER controls casts doubt on the roles of health literacy and access to care in improving survival for these disorders. No significant financial relationships to disclose. [Table: see text]
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Affiliation(s)
- G. A. Abel
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hospital, Boston, MA
| | - K. A. Bertrand
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hospital, Boston, MA
| | - C. C. Earle
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hospital, Boston, MA
| | - F. Laden
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hospital, Boston, MA
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Abel GA, Lee SJ, Viswanath V, Weeks JC. Direct-to-consumer advertising in oncology: A content analysis of print media. J Clin Oncol 2006. [DOI: 10.1200/jco.2006.24.18_suppl.6034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
6034 Background: Direct-to-consumer advertising (DTCA) is an increasingly prevalent and contentious medium of medical communication. Content analysis of cancer-related DTCA, with a focus on how benefit and risk/side effect information is presented, is essential to understanding its potential effect on oncology outcomes. Methods: We reviewed all product-specific DTCA for oncology-related medications appearing in the patient-focused cancer magazines CURE, Coping with Cancer, and MAMM: Women, Cancer and Community during 2005. We assessed the Flesch reading ease score (FRES), calculated with the formula [206.835 - (1.015 x average sentence length) - (84.6 x average syllables per word)], for the benefit and risk/side effect information presented in each advertisement. Ranging from 0 to 100, a FRES of 65 or higher is considered understandable for the average person. We also assessed the largest type size (in mm) and the placement (first, middle or final third of text) of benefits and risks/side effects, as well as the ads’ use of appeals to clinical trial data, cost, celebrity endorsement, physician endorsement, and implied patient testimonials (visual and written). Results: Of 75 ads reviewed, many were repeated, such that 15 unique ads were analyzed. The mean FRES for benefit information was 40.64, while the mean FRES for risks/side effects was 32.30, a difference of 8.34 [95% CI: 1.16, 15.52]. The mean largest benefit type size was 7.10 mm, while the mean largest risk/side effect type size was 2.33 mm, a difference of 4.77 mm [95% CI: 2.35, 7.17]. No ads mentioned cost, and none contained a celebrity or physician endorsement. 53% referenced clinical trials, and 60% offered an implied patient testimonial. In their first third of text, 93% presented benefits; 13% presented risks/side effects. In their final third of text, 27% presented benefits; 93% presented risks/side effects. Conclusion: Oncology print DTCA is difficult to read, as assessed by a standard readability measure. Moreover, compared to risks/side effects, benefits are presented in a larger typeface, earlier in the text, and in language that is modestly easier to read. Oncology providers should be aware of such differences, as they may influence patients’ perceptions of cancer-related medications. No significant financial relationships to disclose.
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Affiliation(s)
- G. A. Abel
- Dana-Farber Cancer Institute, Boston, MA; Fred Hutchinson Cancer Research Center, Seattle, WA
| | - S. J. Lee
- Dana-Farber Cancer Institute, Boston, MA; Fred Hutchinson Cancer Research Center, Seattle, WA
| | - V. Viswanath
- Dana-Farber Cancer Institute, Boston, MA; Fred Hutchinson Cancer Research Center, Seattle, WA
| | - J. C. Weeks
- Dana-Farber Cancer Institute, Boston, MA; Fred Hutchinson Cancer Research Center, Seattle, WA
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Abel GA, Freeman MP. A statistical analysis of ionospheric velocity and magnetic field power spectra at the time of pulsed ionospheric flows. ACTA ACUST UNITED AC 2002. [DOI: 10.1029/2002ja009402] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- G. A. Abel
- British Antarctic Survey; Natural Environment Research Council; Cambridge UK
| | - M. P. Freeman
- British Antarctic Survey; Natural Environment Research Council; Cambridge UK
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Rymer AM, Coates AJ, Svenes K, Abel GA, Linder DR, Narheim B, Thomsen M, Young DT. Cassini Plasma Spectrometer Electron Spectrometer measurements during the Earth swing-by on August 18, 1999. ACTA ACUST UNITED AC 2001. [DOI: 10.1029/2001ja900087] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Abel GA, Coates AJ, Rymer AM, Linder DR, Thomsen MF, Young DT, Dougherty MK. Cassini Plasma Spectrometer observations of bidirectional lobe electrons during the Earth flyby, August 18, 1999. ACTA ACUST UNITED AC 2001. [DOI: 10.1029/2001ja900076] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Abel GA, Chen X, Boden-Albala B, Sacco RL. Social readjustment and ischemic stroke: lack of an association in a multiethnic population. Neuroepidemiology 2000; 18:22-31. [PMID: 9831812 DOI: 10.1159/000026192] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Clinical experience has suggested that stressful life events and ongoing stressful illness, collectively termed 'social readjustment', may precipitate stroke. We investigated the association between a simple in-office evaluation of such stressors and stroke in an urban, multiethnic study population. Cases were patients from the Northern Manhattan Stroke Study with first ischemic stroke; controls were derived through random digit dialing with n:m matching for age, gender, and race-ethnicity. Social readjustment was measured through in-person interview using Amster and Krauss' Geriatric Social Readjustment Rating Scale (GSRRS), a one-time, 35-item, checklist type weighted questionnaire of stressful life events occurring in the previous 6 months. Conditional logistic regression was used to analyze the GSRRS and its quartiles as well as stressful events subgroups, adjusting for education, hypertension, cardiac disease, diabetes, and number of weekly visits as a measure of socialization. Six hundred and fifty-five cases of ischemic stroke and 1,087 controls were utilized. The mean age of the cases was 69.8 years, with 55.4% women, 51.0% Hispanics, 28.4% blacks, and 19.1% whites. GSRRS scores ranged from 0 to 812; the mean score was 205.5 for the cases and 206.2 for the controls. The analysis showed no association between stroke and a 20-point increase on the GSRRS (OR = 1.01, 95% CI = 0.99-1.01). There was also no effect for the second, third or highest versus lowest quartile. No association was found in age, gender or race-ethnic subgroups, or when analyzing negative events, severely threatening events, or ongoing stressful illnesses separately. While this study does not preclude social readjustment as a stroke risk factor, it suggests that the one-time assessment often done in the medical office setting has little relevance for stroke prevention planning.
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Affiliation(s)
- G A Abel
- Department of Neurology, Columbia University College of Physicians and Surgeons, New York, N.Y., USA
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