Prognostic consequences of implementing cancer patient pathways in Denmark: a comparative cohort study of symptomatic cancer patients in primary care

Abstract Background Abdominal cancers represent 30% of all diagnosed cancers. Nevertheless, it is unknown if the general practitioner’s (GP’s) initial cancer suspicion varies for different abdominal cancer types and how this is associated with referrals to standardized cancer patient pathways (CPPs). Objectives To explore initial cancer suspicion in GPs and to investigate how this was associated with GP referrals to CPPs and the duration of the primary care interval (PCI) in 10 different abdominal cancer types. Methods We conducted a cohort study on 1104 incident abdominal cancer patients diagnosed in Denmark in 2016 using a combination of survey and register-based data. Poisson regression was used to estimate associations between GP cancer suspicion, CPP referral and PCI duration. Results The GPs initially suspected cancer or other serious disease in 46–78% of cases, lowest in kidney cancer, and referred 35–65% to a CPP, lowest in oesophageal cancer. The GP’s suspicion at the first presentation was strongly associated with referral to a CPP. The median (0–11 days) and 75th percentile (3–32 days) PCIs varied between the abdominal cancer types. The likelihood of a long PCI was more than 3-fold higher when the GP did not initially suspect cancer. Conclusion In up to half of abdominal cancer patients, there is no initial suspicion of cancer or serious disease. CPPs were used in only one-third to two-thirds of patients, depending on cancer type. For kidney cancer, as well as several abdominal cancers, we need better diagnostic strategies to support GPs to enable effective and efficient referral.

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Tumour stage and implementation of standardised cancer patient pathways: a comparative cohort study

British Journal of General Practice ◽

10.3399/bjgp16x684805 ◽

2016 ◽

Vol 66 (647) ◽

pp. e434-e443 ◽

Cited By ~ 8

Author(s):

Henry Jensen ◽

Marie Louise Tørring ◽

Morten Fenger-Grøn ◽

Frede Olesen ◽

Jens Overgaard ◽

...

Keyword(s):

Cohort Study ◽

Cancer Patient ◽

Tumour Stage ◽

Patient Pathways ◽

Comparative Cohort Study

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Incidentally diagnosed cancer and commonly preceding clinical scenarios: a cross-sectional descriptive analysis of English audit data

BMJ Open ◽

10.1136/bmjopen-2018-028362 ◽

2019 ◽

Vol 9 (9) ◽

pp. e028362 ◽

Cited By ~ 3

Author(s):

Minjoung Monica Koo ◽

Greg Rubin ◽

Sean McPhail ◽

Georgios Lyratzopoulos

Keyword(s):

Primary Care ◽

Cancer Patient ◽

Cancer Patients ◽

Cancer Diagnosis ◽

Cancer Site ◽

Cross Sectional ◽

Incidental Diagnosis ◽

Audit Data ◽

Clinical Scenarios ◽

Incidental Cancer

ObjectivesCancer can be diagnosed in the absence of tumour-related symptoms, but little is known about the frequency and circumstances preceding such diagnoses which occur outside participation in screening programmes. We aimed to examine incidentally diagnosed cancer among a cohort of cancer patients diagnosed in England.DesignCross-sectional study of national primary care audit data on an incident cancer patient population.SettingWe analysed free-text information on the presenting features of cancer patients aged 15 or older included in the English National Audit of Cancer Diagnosis in Primary Care (2009–2010). Patients with screen-detected cancers or prostate cancer were excluded. We examined the odds of incidental cancer diagnosis by patient characteristics and cancer site using logistic regression, and described clinical scenarios leading to incidental diagnosis.ResultsAmong the studied cancer patient population (n=13 810), 520 (4%) patients were diagnosed incidentally. The odds of incidental cancer diagnosis increased with age (p<0.001), with no difference between men and women after adjustment. Incidental diagnosis was most common among patients with leukaemia (23%), renal (13%) and thyroid cancer (12%), and least common among patients with brain (0.9%), oesophageal (0.5%) and cervical cancer (no cases diagnosed incidentally). Variation in odds of incidental diagnosis by cancer site remained after adjusting for age group and sex.There was a range of clinical scenarios preceding incidental diagnoses in primary or secondary care. These included the monitoring or management of pre-existing conditions, routine testing before or after elective surgery, and the investigation of unrelated acute or new conditions.ConclusionsOne in 25 patients with cancer in our population-based cohort were diagnosed incidentally, through different mechanisms across primary and secondary care settings. The epidemiological, clinical, psychological and economic implications of this phenomenon merit further investigation.

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Patient and tumour characteristics associated with inclusion in Cancer patient pathways in Norway in 2015–2016

BMC Cancer ◽

10.1186/s12885-020-06979-y ◽

2020 ◽

Vol 20 (1) ◽

Cited By ~ 1

Author(s):

Yngvar Nilssen ◽

Odd Terje Brustugun ◽

Morten Tandberg Eriksen ◽

Erik Skaaheim Haug ◽

Bjørn Naume ◽

...

Keyword(s):

Prostate Cancer ◽

Cancer Patient ◽

Cancer Patients ◽

Cancer Diagnosis ◽

Waiting Time ◽

Low Income ◽

Breast Cancer Patients ◽

Prostate Cancer Diagnosis ◽

Patient Pathways ◽

Region Of Residence

Abstract Background Cancer patient pathways (CPPs) were implemented in 2015 to reduce waiting time, regional variation in waiting time, and to increase the predictability of cancer care for the patients. The aims of this study were to see if the national target of 70% of all cancer patients being included in a CPP was met, and to identify factors associated with CPP inclusion. Methods All patients registered with a colorectal, lung, breast or prostate cancer diagnosis at the Cancer Registry of Norway in the period 2015–2016 were linked with the Norwegian Patient Registry for CPP information and with Statistics Norway for sociodemographic variables. Multivariable logistic regression examined if the odds of not being included in a CPP were associated with year of diagnosis, age, sex, tumour stage, marital status, education, income, region of residence and comorbidity. Results From 2015 to 2016, 30,747 patients were diagnosed with colorectal, lung, breast or prostate cancer, of whom 24,429 (79.5%) were included in a CPP. Significant increases in the probability of being included in a CPP were observed for colorectal (79.1 to 86.2%), lung (79.0 to 87.3%), breast (91.5 to 97.2%) and prostate cancer (62.2 to 76.2%) patients (p < 0.001). Increasing age was associated with an increased odds of not being included in a CPP for lung (p < 0.001) and prostate cancer (p < 0.001) patients. Colorectal cancer patients < 50 years of age had a two-fold increase (OR = 2.23, 95% CI: 1.70–2.91) in the odds of not being included in a CPP. The odds of no CPP inclusion were significantly increased for low income colorectal (OR = 1.24, 95%CI: 1.00–1.54) and lung (OR = 1.52, 95%CI: 1.16–1.99) cancer patients. Region of residence was significantly associated with CPP inclusion (p < 0.001) and the probability, adjusted for case-mix ranged from 62.4% in region West among prostate cancer patients to 97.6% in region North among breast cancer patients. Conclusions The national target of 70% was met within 1 year of CPP implementation in Norway. Although all patients should have equal access to CPPs, a prostate cancer diagnosis, older age, high level of comorbidity or low income were significantly associated with an increased odds of not being included in a CPP.

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Primary care service use by end-of-life cancer patients: a nationwide population-based cohort study in the United Kingdom

BMC Family Practice ◽

10.1186/s12875-020-01127-8 ◽

2020 ◽

Vol 21 (1) ◽

Author(s):

Wei Gao ◽

Martin Gulliford ◽

Myfanwy Morgan ◽

Irene J. Higginson

Keyword(s):

Primary Care ◽

Cohort Study ◽

United Kingdom ◽

End Of Life ◽

Cancer Patients ◽

Service Use ◽

Care Service ◽

Population Based ◽

Primary Care Service ◽

The United Kingdom

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Equitable access to cancer patient pathways in Norway – a national registry-based study

BMC Health Services Research ◽

10.1186/s12913-021-07250-1 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Frank Olsen ◽

Bjarne K. Jacobsen ◽

Ivar Heuch ◽

Kjell M. Tveit ◽

Lise Balteskard

Keyword(s):

Cancer Patient ◽

Cancer Patients ◽

National Registry ◽

Diagnostic Process ◽

Equitable Access ◽

Place Of Residence ◽

Income Groups ◽

Patient Pathways ◽

Hospital Referral ◽

Risk Of Cancer

Abstract Background In 2015, cancer patient pathways (CPP) were implemented in Norway to reduce unnecessary non-medical delay in the diagnostic process and start of treatment. The main aim of this study was to investigate the equality in access to CPPs for patients with either lung, colorectal, breast or prostate cancer in Norway. Methods National population-based data on individual level from 2015 to 2017 were used to study two proportions; i) patients in CPPs without the cancer diagnosis, and ii) cancer patients included in CPPs. Logistic regression was applied to examine the associations between these proportions and place of residence (hospital referral area), age, education, income, comorbidity and travel time to hospital. Results Age and place of residence were the two most important factors for describing the variation in proportions. For the CPP patients, inconsistent differences were found for income and education, while for the cancer patients the probability of being included in a CPP increased with income. Conclusions The age effect can be related to both the increasing risk of cancer and increasing number of GP and hospital contacts with age. The non-systematic results for CPP patients according to income and education can be interpreted as equitable access, as opposed to the systematic differences found among cancer patients in different income groups. The inequalities between income groups among cancer patients and the inequalities based on the patients’ place of residence, for both CPP and cancer patients, are unwarranted and need to be addressed.

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Primary Care Continuity and Wait Times to Receiving Breast Cancer Chemotherapy: A Population-Based Retrospective Cohort Study Using CanIMPACT Data

Current Oncology ◽

10.3390/curroncol28060405 ◽

2021 ◽

Vol 28 (6) ◽

pp. 4786-4804

Author(s):

Rachel Lin Walsh ◽

Aisha Lofters ◽

Rahim Moineddin ◽

Monika Krzyzanowska ◽

Eva Grunfeld

Keyword(s):

Breast Cancer ◽

Primary Care ◽

Cohort Study ◽

Cancer Patients ◽

Retrospective Cohort Study ◽

Retrospective Cohort ◽

Population Based ◽

Wait Times ◽

Breast Cancer Patients ◽

Breast Cancer Chemotherapy

(1) Background: Wait times to chemotherapy are associated with morbidity and mortality in breast cancer patients; however, it is unclear how primary care physician (PCP) continuity impacts these wait times, or whether this association is different in immigrants, who experience cancer care inequities. We assessed the association between PCP continuity and the contact-to-chemotherapy interval (wait time from when a patient first presents to healthcare to the first day of receiving breast cancer chemotherapy), with a specific look at the immigrant population. (2) Methods: Population-based, retrospective cohort study of women who were diagnosed with stage I–III breast cancer in Ontario who received surgery and adjuvant chemotherapy. We used quantile regression at the median and 90th percentile to quantify the effect of PCP continuity on the contact-to-chemotherapy interval, performing a separate analysis on the immigrant population. (3) Results: Among 12,781 breast cancer patients, including 1706 immigrants, the median contact-to-chemotherapy interval (126 days) was 3.21 days shorter (95% confidence interval (CI) 0.47–5.96) in symptom-detected patients with low PCP continuity, 10.68 days shorter (95% CI 5.36–16.00) in symptom-detected patients with no baseline PCP visits and 17.43 days longer (95% CI 0.90–34.76) in screen-detected immigrants with low PCP continuity compared to the same groups with high PCP continuity. (4) Conclusions: Higher PCP continuity was not associated with a change in the contact-to-chemotherapy interval for most of our study population, but was associated with a marginally longer interval in our symptom-detected population and a shorter contact-to-chemotherapy interval in screen-detected immigrants. This highlights the importance of PCP continuity among immigrants with positive screening results. Additionally, having no PCP visits at baseline was associated with a shorter contact-to-chemotherapy interval in symptom-detected patients.

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Cancer patients’ experiences with urgent referrals to cancer patient pathways

European Journal of Cancer Care ◽

10.1111/ecc.12927 ◽

2018 ◽

Vol 28 (1) ◽

pp. e12927 ◽

Cited By ~ 5

Author(s):

Mette Sandager ◽

Henry Jensen ◽

Henriette Lipczak ◽

Cecilie Dyg Sperling ◽

Peter Vedsted

Keyword(s):

Cancer Patient ◽

Cancer Patients ◽

Patient Pathways

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Primary care service use by end-of-life cancer patients: a nationwide population-based cohort study in the United Kingdom

10.21203/rs.2.14885/v3 ◽

2020 ◽

Author(s):

Wei Gao ◽

Martin Gulliford ◽

Myfanwy Morgan ◽

Irene J Higginson

Keyword(s):

Primary Care ◽

Palliative Care ◽

Cohort Study ◽

End Of Life ◽

Cancer Patients ◽

Care Needs ◽

Explanatory Variables ◽

Care Services ◽

The United Kingdom ◽

Palliative Care Needs

Abstract Background End of life(EoL) care becomes more complex and increasingly takes place in the community, but there is little data on the use of general practice(GP) services to guide care improvement. This study aims to determine the trends and factors associated with GP consultation, prescribing and referral to other care services amongst cancer patients in the last year of life. Methods A retrospective cohort study of cancer patients who died in 2000-2014, based on routinely collected primary care data(the Clinical Practice Research DataLink, CPRD) covering a representative sample of the population in the United Kingdom. Outcome variables were number of GP consultations(primary), number of prescriptions and referral to other care services(yes vs no) in the last year of life. Explanatory variables included socio-demographics, clinical characteristics and the status of palliative care needs recognised or not. The association between outcome and explanatory variables were evaluated using multiple-adjusted risk ratio(aRR). Results Of 68,523 terminal cancer patients, 70% were aged 70+, 75% had comorbidities and 45.5% had palliative care needs recognised. In the last year of life, a typical cancer patient had 43 GP consultations(Standard deviation(SD): 31.7; total=3,031,734), 71.5 prescriptions(SD: 68.0; total=5,074,178), and 21(SD: 13.0) different drugs; 58.0% of patients had at least one referral covering all main clinical specialities. More comorbid conditions, prostate cancer and having palliative care needs recognised were associated with more primary care consultations, more prescriptions and a higher chance of referral(aRRs 1.07-2.03). Increasing age was related to fewer consultations(aRRs 0.77-0.96), less prescriptions(aRR 1.09-1.44), and a higher chance of referral(aRRs 1.08-1.16) but less likely to have palliative care needs recognised(aRRs 0.53-0.89). Conclusions GPs are very involved in end of life care of cancer patients, most of whom having complex care needs, i.e. older age, comorbidity and polypharmacy. This highlights the importance of enhancing primary palliative care skills among GPs and the imperative of greater integration of primary care with other healthcare professionals including oncologists, palliative care specialists, geriatricians and pharmacists. Research into the potential of deprescribing is warranted. Older patients have poorer access to both primary care and palliative care need to be addressed in future practices.

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