C Dobson

Symptoms and other factors associated with time to diagnosis and stage of lung cancer: a prospective cohort study

Background:This prospective cohort study aimed to identify symptom and patient factors that influence time to lung cancer diagnosis and stage at diagnosis.Methods:Data relating to symptoms were collected from patients upon referral with symptoms suspicious of lung cancer in two English regions; we also examined primary care and hospital records for diagnostic routes and diagnoses. Descriptive and regression analyses were used to investigate associations between symptoms and patient factors with diagnostic intervals and stage.Results:Among 963 participants, 15.9% were diagnosed with primary lung cancer, 5.9% with other thoracic malignancies and 78.2% with non-malignant conditions. Only half the cohort had an isolated first symptom (475, 49.3%); synchronous first symptoms were common. Haemoptysis, reported by 21.6% of cases, was the only initial symptom associated with cancer. Diagnostic intervals were shorter for cancer than non-cancer diagnoses (91 vs 124 days, P=0.037) and for late-stage than early-stage cancer (106 vs 168 days, P=0.02). Chest/shoulder pain was the only first symptom with a shorter diagnostic interval for cancer compared with non-cancer diagnoses (P=0.003).Conclusions:Haemoptysis is the strongest symptom predictor of lung cancer but occurs in only a fifth of patients. Programmes for expediting earlier diagnosis need to focus on multiple symptoms and their evolution.

Attitudes and beliefs of non-participants in a population-based screening programme for colorectal cancer

Uptake of colorectal cancer screening programmes needs to be improved or at least maintained in order to achieve projected reductions in mortality and morbidity. Understanding the origins of non‐participation in screening is therefore important.

Symptoms and patient factors associated with longer time to diagnosis for colorectal cancer: results from a prospective cohort study

Background:The objective of this study is to investigate symptoms, clinical factors and socio-demographic factors associated with colorectal cancer (CRC) diagnosis and time to diagnosis.Methods:Prospective cohort study of participants referred for suspicion of CRC in two English regions. Data were collected using a patient questionnaire, primary care and hospital records. Descriptive and regression analyses examined associations between symptoms and patient factors with total diagnostic interval (TDI), patient interval (PI), health system interval (HSI) and stage.Results:A total of 2677 (22%) participants responded; after exclusions, 2507 remained. Participants were diagnosed with CRC (6.1%, 56% late stage), other cancers (2.0%) or no cancer (91.9%). Half the cohort had a solitary first symptom (1332, 53.1%); multiple first symptoms were common. In this referred population, rectal bleeding was the only initial symptom more frequent among cancer than non-cancer cases (34.2% vs 23.9%, P=0.004). There was no evidence of differences in TDI, PI or HSI for those with cancer vs non-cancer diagnoses (median TDI CRC 124 vs non-cancer 138 days, P=0.142). First symptoms associated with shorter TDIs were rectal bleeding, change in bowel habit, ‘feeling different’ and fatigue/tiredness. Anxiety, depression and gastro-intestinal co-morbidities were associated with longer HSIs and TDIs. Symptom duration-dependent effects were found for rectal bleeding and change in bowel habit.Conclusions:Doctors and patients respond less promptly to some symptoms of CRC than others. Healthcare professionals should be vigilant to the possibility of CRC in patients with relevant symptoms and mental health or gastro-intestinal comorbidities.

Patient delay in cancer diagnosis: what do we really mean and can we be more specific?

BackgroundEarly diagnosis is a key focus of cancer control because of its association with survival. Delays in diagnosis can occur throughout the diagnostic pathway, within any one of its three component intervals: the patient interval, the primary care interval and the secondary care interval.DiscussionA key focus for help-seeking research in patients with symptoms of cancer has been the concept of ‘delay’. The literature is plagued by definitional and semantic problems, which serve to hinder comparison between studies. Use of the word ‘delay’ has been criticised as judgemental and potentially stigmatising, because of its implications of intent. However, the suggested alternatives (time to presentation, appraisal interval, help-seeking interval and postponement of help-seeking) still fail to accurately define the concept in hand, and often conflate three quite separate ideas; that of an interval, that of an unacceptably long interval, and that of a specific event which caused delay in the diagnostic process. We discuss the need to disentangle current terminology and suggest the term ‘prolonged interval’ as a more appropriate alternative. Most studies treat the patient interval as a dichotomous variable, with cases beyond a specified time point classified as ‘delay’. However, there are inconsistencies in both where this line is drawn, ranging from one week to three months, and how, with some studies imposing seemingly arbitrary time points, others utilising the median as a divisive tool or exploring quartiles within their data. This not only makes comparison problematic, but, as many studies do not differentiate between cancer site, also imposes boundaries which are not necessarily site-relevant. We argue that analysis of the patient interval should be based on presenting symptom, as opposed to pathology, to better reflect the context of the help-seeking interval, and suggest how new definitional boundaries could be developed.SummaryThe word ‘delay’ is currently (conf)used to describe diverse conceptualisations of ‘delay’ and more mindful, and discerning language needs to be developed to enable a more sophisticated discussion. By stratifying help-seeking by presenting symptom(s), more accurate and informative analyses could be produced which, in turn, would result in more accurately targeted early diagnosis interventions.

OC-070 Perceived Delay among Patients with Colorectal, Stomach and Oesophageal Cancer: Analysis of Data from a National GP Audit

Introduction The UK has significantly poorer cancer survival rates than comparable countries and diagnostic delay is perceived to be a significant contributory factor to this. The RCGP National Audit of Cancer Diagnosis in Primary Care (2009/10) included data on 3655 patients with colorectal and gastro-oesophageal cancer, including free text comments on avoidable delays in diagnosis, as perceived by the participating GPs. The aim of this study was to identify the principal causes of delay, as perceived by GPs, and how they differ by cancer site. Methods Avoidable delay was reported for 36% of patients with colorectal cancer, 37% gastric cancer and 35% oesophageal cancer. Free text reports of the nature of the delay were available for 753 (28%) colorectal, 87 (28%) gastric and 164 (27%) oesophageal cancer patients. An extended version of The Model of Pathways to Treatment (Walter et al 2011) was developed for use as the analytical framework. Comments were categorised by CD with uncertain cases discussed and resolved with GR. In order to validate GP perceptions of diagnostic delay we compared categorised primary care and referral intervals for patients with and without perceived delay. Results Primary care and referral intervals were significantly longer for patients with a perceived avoidable diagnostic delay (p = <0.0001), for all three cancer sites. The commonest reasons for delay for colorectal, gastric and oesophageal cancer patients were GP appraisal (29%, 14%, 16% respectively), referral delays (e.g. routine rather than 2 week wait) (13%, 23%, 32% respectively) and investigation delays (28%, 34%, 27% respectively). For colorectal cancer patients, help seeking delay was also a significant cause of delay (8%). Because causes of delay were reported by GPs there was a potential reporting bias, with delays occurring prior to first consultation or in secondary care possibly being under-reported. Conclusion Diagnostic delay for patients with upper and lower GI cancers is multi-faceted, with GP appraisal and type of referral perceived as substantial contributors. Interventions aimed at reducing the time to diagnosis should be targeted at the key causes and settings of delay for different cancer sites. Disclosure of Interest None Declared Reference Walter, F. Webster, A., Scott, S. & Emery, J. (2012) ‘The Andersen Model of total patient delay: A systematic review of its application in cancer diagnosis.’ Journal of Health Services Research and Policy Vol.17, No.2, pp.110–118.