Multicentre service evaluation of presentation of newly diagnosed cancers and type 1 diabetes in children in the UK during the COVID-19 pandemic

BackgroundThe COVID-19 pandemic led to changes in patterns of presentation to emergency departments. Child health professionals were concerned that this could contribute to the delayed diagnosis of life-threatening conditions, including childhood cancer (CC) and type 1 diabetes (T1DM). Our multicentre, UK-based service evaluation assessed diagnostic intervals and disease severity for these conditions.MethodsWe collected presentation route, timing and disease severity for children with newly diagnosed CC in three principal treatment centres and T1DM in four centres between 1 January and 31 July 2020 and the corresponding period in 2019. Total diagnostic interval (TDI), patient interval (PI), system interval (SI) and disease severity across different time periods were compared.ResultsFor CCs and T1DM, the route to diagnosis and severity of illness at presentation were unchanged across all time periods. Diagnostic intervals for CCs during lockdown were comparable to that in 2019 (TDI 4.6, PI 1.1 and SI 2.1 weeks), except for an increased PI in January–March 2020 (median 2.7 weeks). Diagnostic intervals for T1DM during lockdown were similar to that in 2019 (TDI 16 vs 15 and PI 14 vs 14 days), except for an increased PI in January–March 2020 (median 21 days).ConclusionsThere is no evidence of diagnostic delay or increased illness severity for CC or T1DM, during the first phase of the pandemic across the participating centres. This provides reassuring data for children and families with these life-changing conditions.

Delayed Colorectal Cancer Diagnosis during the COVID-19 Pandemic in Alberta: A Framework for Analyzing Barriers to Diagnosis and Generating Evidence to Support Health System Changes Aimed at Reducing Time to Diagnosis

The frequency of colorectal cancer (CRC) diagnosis has decreased due to the COVID-19 pandemic. Health system planning is needed to address the backlog of undiagnosed patients. We developed a framework for analyzing barriers to diagnosis and estimating patient volumes under different system relaunch scenarios. This retrospective study included CRC cases from the Alberta Cancer Registry for the pre-pandemic (1 January 2016–4 March 2020) and intra-pandemic (5 March 2020–1 July 2020) periods. The data on all the diagnostic milestones in the year prior to a CRC diagnosis were obtained from administrative health data. The CRC diagnostic pathways were identified, and diagnostic intervals were measured. CRC diagnoses made during hospitalization were used as a proxy for severe disease at presentation. A modified Poisson regression analysis was used to estimate the adjusted relative risk (adjRR) and a 95% confidence interval (CI) for the effect of the pandemic on the risk of hospital-based diagnoses. During the study period, 8254 Albertans were diagnosed with CRC. During the pandemic, diagnosis through asymptomatic screening decreased by 6·5%. The adjRR for hospital-based diagnoses intra-COVID-19 vs. pre-COVID-19 was 1.24 (95% CI: 1.03, 1.49). Colonoscopies were identified as the main bottleneck for CRC diagnoses. To clear the backlog before progression is expected, high-risk subgroups should be targeted to double the colonoscopy yield for CRC diagnosis, along with the need for a 140% increase in monthly colonoscopy volumes for a period of 3 months. Given the substantial health system changes required, it is unlikely that a surge in CRC cases will be diagnosed over the coming months. Administrators in Alberta are using these findings to reduce wait times for CRC diagnoses and monitor progression.

Diagnostic intervals in oropharyngeal cancers from a primary care perspective: a ten-year case note review

Background Rates of oropharyngeal (OP) cancer are increasing and mortality is related to stage at diagnosis. Early diagnosis is vital to improving patient outcomes.Aim To describe current general practice pathways and time intervals in OP cancer and: a) compare to current National Institute for Health and Care Excellence guidance to refer from general practitioners (GPs) to general medical dentists (dentists); and b) referral pathways for pharyngeal cancers.Design and setting A ten-year retrospective study of patients diagnosed with OP cancer in one suburban general practice in England using GP notes, including secondary care correspondence.Results There were 12 cases of OP cancer; six oral and six pharyngeal. There were marked differences in referral pathways and time intervals for people with visible, or palpable, oral cancers and those with non-visible, or impalpable, pharyngeal cancers. No one had GP to dentist referral. General practice 'safety-netting' or follow-up was not commonly recorded.Conclusion GPs are pivotal in diagnosing symptomatic OP cancers. General practice and dental teams encountering symptoms of uncertain aetiology (for example, pharyngitis) should offer safety-netting to shorten patient intervals to re-attendance. Pathways for oral cancer referral were usually clear and linear. Pathways for pharyngeal cancer were usually complex, with much longer time intervals in primary and secondary care, and would benefit from a single national referral pathway to ENT.

A multi-centre service evaluation of the impact of the COVID-19 pandemic on presentation of newly diagnosed cancers and type 1 diabetes in children in the UK

BackgroundThe COVID-19 pandemic led to changes in patterns of presentation to Emergency Departments (ED). Child health professionals were concerned that this could contribute to the delayed diagnosis of life-threatening conditions, including childhood cancer (CC) and type 1 diabetes (T1DM). Our multicentre, UK-based service evaluation assessed diagnostic intervals and disease severity for these conditions.MethodsWe collected presentation route, timing and disease severity for children with newly diagnosed CC in three principal treatment centres, and T1DM in four centres between 1stJanuary – 31st July 2020 and the corresponding period in 2019. We assessed the impact of lockdown on total diagnostic interval (TDI), patient interval (PI), system interval (SI) and disease severity.FindingsFor CCs and T1DM, the route to diagnosis and severity of illness at presentation were unchanged across all time periods. Diagnostic intervals for CCs during lockdown were comparable to that in 2019 (TDI 4.6, PI 1.1 and SI 2.1 weeks), except for an increased PI in Jan-Mar 2020 (median 2.7 weeks). Diagnostic intervals for T1DM during lockdown were similar to that in 2019 (TDI 16 vs 15 and PI 14 vs 14 days), except for an increased PI in Jan-Mar 2020 (median 21 days).InterpretationThere is no evidence of diagnostic delay or increased illness severity for CC or T1DM, during the first phase of the pandemic across the participating centres. This provides reassuring data for children and families with these life-changing conditions.Research in ContextEvidence before this studyThis project was initiated after the first national lockdown in March 2020 during COVID-19 pandemic in the UK. At the design stage, Medline was searched (with no language limit), using the keywords ((Cancer) OR (neoplasm) OR (Type 1 diabetes mellitus)) AND ((Covid-19) OR (SARS-CoV-2) OR (Pandemics)) AND ((Emergency department attendances) OR (diabetes ketoacidosis) OR (Delayed diagnosis) OR (interval) OR (wait)) to identify publications reporting the impact of the pandemic and public health measures on both overall and paediatric healthcare services. Significant changes in service utilisation in the UK were reported following the commencement of the first lockdown, including a 49% reduction in emergency department attendances in the week following the lockdown; and two adult studies reported that referral via the urgent two-week wait cancer referral diagnoses decreased by 84% from Mar-May and 60% in June 2020. As for Type 1 diabetes (T1DM), a 30 patient UK-study reported an increase in newly diagnosed T1DM during the first six weeks of lockdown. Increased proportions of severe diabetic ketoacidosis (DKA) at presentation were also reported in an Italian survey involving 53 paediatric diabetes centres. Through the search we identified a need for multi-centre, more thorough assessment on referral pathways, time taken from symptom onset to diagnosis, and its association with severity at presentation for children diagnosed with life-changing conditions during the national lockdown.Added value of this studyOur findings suggest that the first national lockdown in the UK were not associated with delayed diagnosis of childhood cancer or type 1 diabetes at participating centres. This provides reassuring information for children and families with these life-changing conditions.ImplicationWe believe that our study can play a key role in allaying parental and professional concern. it is important to establish whether subsequent public health measures have impacted the diagnostic interval in the context of an evolving backlog of patient referrals across the UK.

Diagnosed with a Rare Cancer: Experiences of Adult Sarcoma Survivors with the Healthcare System—Results from the SURVSARC Study

The aim of this study was to explore the experience of rare cancer patients with the healthcare system and examine differences between age groups (adolescents and young adults (AYA, 18–39 years), older adults (OA, 40–69 years) and elderly (≥70 years)). Dutch sarcoma patients, 2–10 years after diagnosis, completed a questionnaire on their experience with the healthcare system, satisfaction with care, information needs, patient and diagnostic intervals (first symptom to first doctor’s visit and first doctor’s visit to diagnosis, respectively) and received supportive care. In total, 1099 patients completed the questionnaire (response rate 58%): 186 AYAs, 748 OAs and 165 elderly. Many survivors experienced insufficient medical and non-medical guidance (32% and 38%), although satisfaction with care was rated good to excellent by 94%. Both patient and diagnostic intervals were >1 month for over half of the participants and information needs were largely met (97%). AYAs had the longest patient and diagnostic intervals, experienced the greatest lack of (non-)medical guidance, had more desire for patient support groups and used supportive care most often. This nationwide study among sarcoma survivors showed that healthcare experiences differ per age group and identified needs related to the rarity of these tumors, such as improvements concerning (non-)medical guidance and diagnostic intervals.

Barriers and facilitators to colorectal cancer diagnosis in New Zealand: a qualitative study

Background New Zealand (NZ) has high rates of colorectal cancer but low rates of early diagnosis. Due to a lack of understanding of the pre-diagnostic experience from the patient’s perspective, it is necessary to investigate potential patient and health system factors that contribute to longer diagnostic intervals. Previous qualitative studies have discussed delays using The Model of Pathways to Treatment, but this has not been explored in the NZ context. This study aimed to understand the patient experience and perception of their general practitioner (GP) through the diagnostic process in the Waikato region of NZ. In particular, we sought to investigate potential barriers and facilitators that contribute to longer diagnostic intervals. Methods Ethical approval for this study was granted by the New Zealand Health and Disability Ethics Committee. Twenty-eight participants, diagnosed with colorectal cancer, were interviewed about their experience. Semi-structured interviews were audio recorded, transcribed verbatim and analysed thematically using The Model of Pathways to Treatment framework (intervals: appraisal, help-seeking, diagnostic). Results Participant appraisal of symptoms was a barrier to prompt diagnosis, particularly if symptoms were normalised, intermittent, or isolated in occurrence. Successful self-management techniques also resulted in delayed help-seeking. However if symptoms worsened, disruption to work and daily routines were important facilitators to seeking a GP consultation. Participants positively appraised GPs if they showed good technical competence and were proactive in investigating symptoms. Negative GP appraisals were associated with a lack of physical examinations and misdiagnosis, and left participants feeling dehumanised during the diagnostic process. However high levels of GP interpersonal competence could override poor technical competence, resulting in an overall positive experience, even if the cancer was diagnosed at an advanced stage. Māori participants often appraised symptoms inclusive of their sociocultural environment and considered the impact of their symptoms in relation to family. Conclusions The findings of this study highlight the importance of tailored colorectal cancer symptom communication in health campaigns, and indicate the significance of the interpersonal competence aspect of GP-patient interactions. These findings suggest that interpersonal competence be overtly displayed in all GP interactions to ensure a higher likelihood of a positive experience for the patient.

Barriers and Facilitators to Colorectal Cancer Diagnosis in New Zealand: A Qualitative Study

Background: New Zealand (NZ) has high rates of colorectal cancer but low rates of early diagnosis. Due to a lack of understanding of the pre-diagnostic experience from the patient’s perspective, it is necessary to investigate potential patient and health system factors that contribute to longer diagnostic intervals. Previous qualitative studies have discussed delays using The Model of Pathways to Treatment, but this has not been explored in the NZ context. This study aimed to understand the patient experience and perception of their general practitioner (GP) through the diagnostic process in the Waikato region of NZ. In particular, we sought to investigate potential barriers and facilitators that contribute to longer diagnostic intervals. Methods: Ethical approval for this study was granted by the New Zealand Health and Disability Ethics Committee. Twenty-eight participants, diagnosed with colorectal cancer, were interviewed about their experience. Semi-structured interviews were audio recorded, transcribed verbatim and analysed thematically using The Model of Pathways to Treatment framework (intervals: appraisal, help-seeking, diagnostic). Results: Participant appraisal of symptoms was a barrier to prompt diagnosis, particularly if symptoms were normalised, intermittent, or isolated in occurrence. Successful self-management techniques also resulted in delayed help-seeking. However if symptoms worsened, disruption to work and daily routines were important facilitators to seeking a GP consultation. Participants positively appraised GPs if they showed good technical competence and were proactive in investigating symptoms. Negative GP appraisals were associated with a lack of physical examinations and misdiagnosis, and left participants feeling dehumanised during the diagnostic process. However high levels of GP interpersonal competence could override poor technical competence, resulting in an overall positive experience, even if the cancer was diagnosed at an advanced stage. Māori participants often appraised symptoms inclusive of their sociocultural environment and considered the impact of their symptoms in relation to family. Conclusions: The findings of this study highlight the importance of tailored colorectal cancer symptom communication in health campaigns, and indicate the significance of the interpersonal competence aspect of GP-patient interactions. These findings suggest that interpersonal competence be overtly displayed in all GP interactions to ensure a higher likelihood of a positive experience for the patient.

Barriers and Facilitators to Colorectal Cancer Diagnosis in New Zealand: A Qualitative Study

Background: New Zealand (NZ) has high rates of colorectal cancer but low rates of early diagnosis. Due to a lack of understanding of the pre-diagnostic experience from the patient’s perspective, it is necessary to investigate potential patient and health system factors that contribute to longer diagnostic intervals. Previous qualitative studies have discussed delays using The Model of Pathways to Treatment, but this has not been explored in the NZ context. This study aimed to understand the patient experience and perception of their general practitioner (GP) through the diagnostic process in the Waikato region of NZ. In particular, we sought to investigate potential barriers and facilitators that contribute to longer diagnostic intervals.Methods: Ethical approval for this study was granted by the New Zealand Health and Disability Ethics Committee. Twenty-eight participants, diagnosed with colorectal cancer, were interviewed about their experience. Semi-structured interviews were audio recorded, transcribed verbatim and analysed thematically using The Model of Pathways to Treatment framework (intervals: appraisal, help-seeking, diagnostic).Results: Participant appraisal of symptoms was a barrier to prompt diagnosis, particularly if symptoms were normalised, intermittent, or isolated in occurrence. Successful self-management techniques also resulted in delayed help-seeking. However if symptoms worsened, disruption to work and daily routines were important facilitators to seeking a GP consultation. Participants positively appraised GPs if they showed good technical competence and were proactive in investigating symptoms. Negative GP appraisals were associated with a lack of physical examinations and misdiagnosis, and left participants feeling dehumanised during the diagnostic process. However high levels of GP interpersonal competence could override poor technical competence, resulting in an overall positive experience, even if the cancer was diagnosed at an advanced stage. Māori participants often appraised symptoms inclusive of their sociocultural environment and considered the impact of their symptoms in relation to family.Conclusions: The findings of this study highlight the importance of tailored colorectal cancer symptom communication in health campaigns, and indicate the significance of the interpersonal competence aspect of GP-patient interactions. These findings suggest that interpersonal competence be overtly displayed in all GP interactions to ensure a higher likelihood of a positive experience for the patient.

Extent and Predictors of Delays in Diagnosis of Cervical Cancer in Addis Ababa, Ethiopia: A Population-Based Prospective Study

PURPOSE A substantial proportion of cervical cancers are diagnosed at advanced stage in Ethiopia. Therefore, the aim of this study was to determine the extent and predictors of delays in cervical cancer diagnosis in Addis Ababa. PATIENTS AND METHODS We prospectively recruited 231 patients with cervical cancer diagnosed from January 1, 2017, to June 30, 2018, in 7 health facilities in Addis Ababa, representing 99% of all cervical cancers recorded in the Addis Ababa population-based cancer registry. A structured questionnaire on patients’ experience was administered face to face by trained interviewers. Health-seeking intervals > 90 days (date from recognition of symptoms to medical consultation) and diagnostic intervals > 30 days (dates from medical consultation to diagnostic confirmation) were categorized as delayed. Factors associated with these delays were assessed using multivariable binary logistic regression models. RESULTS The median health-seeking and diagnostic intervals for patients with cervical cancer in Addis Ababa were 10 and 97 days, respectively. Approximately one quarter of the patients were delayed in seeking medical consultation, and three fourths of the patients had delayed diagnostic confirmation. Factors associated with health-seeking delays included poor cervical cancer awareness, practicing of religious rituals, and waiting for additional symptoms before visiting a health facility. Factors associated with diagnostic delays included first contact with primary health care units and visits to ≥ 4 different health facilities before diagnosis. CONCLUSION A considerable proportion of patients with cervical cancer in Addis Ababa have delays in seeking medical care and diagnostic conformation. These findings reinforce the need for programs to enhance awareness about cervical cancer signs and symptoms and the importance of early diagnosis in the community and among health care providers.