Rikke Pilegaard Hansen

Delay in diagnosis: the experience in Denmark

Background:Denmark has poorer 5-year survival rates than many other Western European countries, and cancer patients tend to have more advanced stages at diagnosis than those in other Scandinavian countries. Part of this may be due to delay in diagnosis. The aim of this paper is to give an overview of the initiatives currently underway to reduce delays.Methods:Description of Danish actions to reduce delay.Results:Results of surveys of patient-, doctor- and system-related delays are presented and so are the political initiatives to ensure that cancer is seen as an acute disease.Conclusion:In future, fast-track diagnosis and treatment will be provided for suspected cancers and access to general diagnostic investigations will be improved. A large national experiment with cancer seen as an acute disease is currently being implemented, and as yet the results are unknown.

Time intervals from first symptom to treatment of cancer: a cohort study of 2,212 newly diagnosed cancer patients

BackgroundDelay in diagnosis of cancer may worsen prognosis. The aim of this study is to explore patient-, general practitioner (GP)- and system-related delay in the interval from first cancer symptom to diagnosis and treatment, and to analyse the extent to which delays differ by cancer type.MethodsPopulation-based cohort study conducted in 2004-05 in the County of Aarhus, Denmark (640,000 inhabitants). Data were collected from administrative registries and questionnaires completed by GPs on 2,212 cancer patients newly diagnosed during a 1-year period. Median delay (in days) with interquartile interval (IQI) was the main outcome measure.ResultsMedian total delay was 98 days (IQI 57-168). Most of the total delay stemmed from patient (median 21 days (7-56)) and system delay (median 55 days (32-93)). Median GP delay was 0 (0-2) days. Total delay was shortest among patients with ovarian (median 60 days (45-112)) and breast cancer (median 65 days (39-106)) and longest among patients with prostate (median 130 days (89-254)) and bladder cancer (median 134 days (93-181)).ConclusionSystem delay accounted for a substantial part of the total delay experienced by cancer patients. This points to a need for shortening clinical pathways if possible. A long patient delay calls for research into patient awareness of cancer. For all delay components, special focus should be given to the 4th quartile of patients with the longest time intervals and we need research into the quality of the diagnostic work-up process. We found large variations in delay for different types of cancer. Improvements should therefore target both the population at large and the specific needs associated with individual cancer types and their symptoms.

Time to diagnosis and mortality in colorectal cancer: a cohort study in primary care

Background:The relationship between the diagnostic interval and mortality from colorectal cancer (CRC) is unclear. This association was examined by taking account of important confounding factors at the time of first presentation of symptoms in primary care.Methods:A total of 268 patients with CRC were included in a prospective, population-based study in a Danish county. The diagnostic interval was defined as the time from first presentation of symptoms until diagnosis. We analysed patients separately according to the general practitioners interpretation of symptoms. Logistic regression was used to estimate 3-year mortality odds ratios as a function of the diagnostic interval using restricted cubic splines and adjusting for tumour site, comorbidity, age, and sex.Results:In patients presenting with symptoms suggestive of cancer or any other serious illness, the risk of dying within 3 years decreased with diagnostic intervals up to 5 weeks and then increased (P=0.002). In patients presenting with vague symptoms, the association was reverse, although not statistically significant.Conclusion:Detecting cancer in primary care is two sided: aimed at expediting ill patients while preventing healthy people from going to hospital. This likely explains the counterintuitive findings; but it does not explain the increasing mortality with longer diagnostic intervals. Thus, this study provides evidence for the hypothesis that the length of the diagnostic interval affects mortality in CRC patients.

Evidence of increasing mortality with longer diagnostic intervals for five common cancers: a cohort study in primary care.

BACKGROUND Early diagnosis is considered a key factor in improving the outcomes in cancer therapy; it remains unclear, however, whether long pre-diagnostic patient pathways influence clinical outcomes negatively. The aim of this study was to assess the association between the length of the diagnostic interval and the five-year mortality for the five most common cancers in Denmark while addressing known biases. METHODS A total of 1128 patients with colorectal, lung, melanoma skin, breast or prostate cancer were included in a prospective, population-based study in a Danish county. The diagnostic interval was defined as the time from the first presentation of symptoms in primary care till the date of diagnosis. Each type of cancer was analysed separately and combined, and all analyses were stratified according to the general practitioners (GPs) interpretation of the presenting symptoms. We used conditional logistic regression to estimate five-year mortality odds ratios as a function of the diagnostic interval using restricted cubic splines and adjusting for comorbidity, age, sex and type of cancer. RESULTS We found increasing mortality with longer diagnostic intervals among the approximately 40% of the patients who presented in primary care with symptoms suggestive of cancer or any other serious illness. In the same group, very short diagnostic intervals were also associated with increased mortality. Patients presenting with vague symptoms not directly related to cancer or any other serious illness had longer diagnostic intervals and the same survival probability as those who presented with cancer suspicious/serious symptoms. For the former, we found no statistically significant association between the length of the diagnostic interval and mortality. CONCLUSION In full coherence with clinical logic, the healthcare system instigates prompt investigation of seriously ill patients. This likely explains the counter-intuitive findings of high mortality with short diagnostic intervals; but it does not explain the increasing mortality with longer diagnostic intervals. Thus, the study provides further evidence for the hypothesis that the length of the diagnostic interval affects mortality negatively.

Diagnostic interval and mortality in colorectal cancer: U-shaped association demonstrated for three different datasets.

OBJECTIVE To test the theory of a U-shaped association between time from the first presentation of symptoms in primary care to the diagnosis (the diagnostic interval) and mortality after diagnosis of colorectal cancer (CRC). STUDY DESIGN AND SETTING Three population-based studies in Denmark and the United Kingdom using data from general practitioners questionnaires, interviewer-administered patient questionnaires, and primary care records, respectively. RESULTS Despite variations in the potential selection and information bias when using different methods of identifying the date of first presentation, the association between the length of the diagnostic interval and 5-year mortality rate after the diagnosis of CRC was the same for all three types of data: displaying a U-shaped association with decreasing and subsequently increasing mortality with longer diagnostic intervals. CONCLUSION Unknown confounding and in particular confounding by indication is likely to explain the counterintuitive findings of higher mortality among patients with very short diagnostic intervals, but cannot explain the increasing mortality with longer diagnostic intervals. The results support the theory that longer diagnostic intervals cause higher mortality in patients with CRC.

Social support, gender and patient delay

BACKGROUND: The purpose of this study was to examine the relationship between perceived social support and patient delay (PD) among female and male cancer patients.METHODS: A population-based study with register-sampled cancer patients was designed. Patient delay was defined as the time interval between the patients experience of the first symptom and the first contact with a health-care professional. Both dates were provided by the patients (n=910). The patients completed a purpose-designed questionnaire, which assessed the patients perceptions of how the partner reacted (‘Partner Avoidance’ and ‘Partner Support’) and how others in the social network responded (‘Other Avoidance’ and ‘Other Support’) to the patients worries about the symptoms. The associations between the social support subscales and PD were analysed separately for men and women.RESULTS: In female patients, Partner Support and Other Support were associated with shorter PD, whereas Other Avoidance was associated with longer PD. In the multivariate analysis, Other Avoidance remained associated with longer PD. Moreover, disclosure of symptoms to someone reduced the likelihood of a long PD in female patients. In male patients, none of the social support scales significantly increased or decreased the risk of a long PD in the univariate analysis, but Partner Support significantly decreased risk of a long PD in the multivariate analysis.CONCLUSIONS: The results of this study suggest that social support and avoidance from network members influence length of PD differently in male and female cancer patients. This gender difference may explain previous mixed findings obtained in this field.

Patient Delay in Colorectal Cancer Patients: Associations with Rectal Bleeding and Thoughts about Cancer

Rectal bleeding is considered to be an alarm symptom of colorectal cancer. However, the symptom is seldom reported to the general practitioner and it is often assumed that patients assign the rectal bleeding to benign conditions. The aims of this questionnaire study were to examine whether rectal bleeding was associated with longer patient delays in colorectal cancer patients and whether rectal bleeding was associated with cancer worries. All incident colorectal cancer patients during a 1-year period in the County of Aarhus, Denmark, received a questionnaire. 136 colorectal cancer patients returned the questionnaire (response rate: 42%). Patient delay was assessed as the interval from first symptom to help-seeking and was reported by the patient. Patients with rectal bleeding (N = 81) reported longer patient intervals than patients without rectal bleeding when adjusting for confounders including other symptoms such as pain and changes in bowel habits (HR = 0.43; p = 0.004). Thoughts about cancer were not associated with the patient interval (HR = 1.05; p = 0.887), but more patients with rectal bleeding reported to have been wondering if their symptom(s) could be due to cancer than patients without rectal bleeding (chi2 = 15.29; p<0.001). Conclusively, rectal bleeding was associated with long patient delays in colorectal cancer patients although more patients with rectal bleeding reported to have been wondering if their symptom(s) could be due to cancer than patients without rectal bleeding. This suggests that assignment of symptoms to benign conditions is not the only explanation of long patient delays in this patient group and that barriers for timely help-seeking should be examined.

Secondary care intervals before and after the introduction of urgent referral guidelines for suspected cancer in Denmark: a comparative before-after study

BackgroundUrgent referral for suspected cancer was implemented in Denmark on 1 April 2008 to reduce the secondary care interval (i.e. the time interval from the general practitioner’s first referral of a patient to secondary health care until treatment is initiated). However, knowledge about the association between the secondary care interval and urgent referral remains scarce. The aim of this study was to analyse how the secondary care interval changed after the introduction of urgent referral.MethodsThis was a retrospective population-based study of 6,518 incident cancer patients based on questionnaire data from the patients’ GPs. Analyses were stratified with patients discharged from Vejle Hospital in one stratum and patients from other hospitals in another because Vejle Hospital initiated urgent referrals several years prior to the national implementation. Further, analyses were stratified according to symptom presentation and whether or not the GP referred the patient on suspicion of cancer. Symptom presentation was defined as with or without alarm symptoms based on GP interpretation of early symptoms.ResultsThe median secondary care interval decreased after the introduction of urgent referral. Patients discharged from Vejle Hospital tended to have shorter secondary care intervals than patients discharged from other hospitals. The strongest effect was seen in patients with alarm symptoms and those who were referred by their GP on suspicion of cancer. Breast cancer patients from Vejle Hospital experienced an even shorter secondary care interval after the national introduction of urgent referrals.ConclusionUrgent referral had a positive effect on the secondary care interval, and Vejle Hospital remarkably managed to shorten the intervals even further. This finding indicates that the shorter secondary care intervals not only result from the urgent referral guidelines, but also involve other factors.

Agreement between patient-reported and doctor-reported patient intervals and date of first symptom presentation in cancer diagnosis - A population-based questionnaire study

BACKGROUND The concept of delay in cancer diagnosis has been a scientific issue for decades, and there is still no standardised and validated way to measure the time intervals. One of the intervals that are difficult to measure is the patient interval (i.e. the period from the patients first symptom until the first presentation to the health care system) because dates of symptom onset and first presentation are difficult to establish precisely. Further, since patients may have another experience of the diagnostic pathway than e.g. the general practitioner (GP), a reasonable question remains whether patients and GPs agree on these important milestones. The objective of this study was to analyse the agreement between patient-reported and GP-reported patient intervals and date of first presentation of cancer-related symptom(s) to the GP. METHODS On the basis of a cohort study, we included incident cancer patients from the former Aarhus County from 1 September, 2004 to 31 August, 2005. Both patients and GPs reported the length of the patient interval and the date of the first presentation to the GP with a cancer-related symptom measured by self-administered questionnaires. Agreement was measured using agreement-survival plots and Lins concordance correlation coefficient (CCC). RESULTS There was full agreement between GP- and patient-reported patient intervals in 21.0% of all the cancer cases. In 50.1% of cases, patients and GPs agreed about the patient interval within a margin of one month. There was full agreement between GP- and patient-reported date of first presentation in 37.5% of the cancer cases and within one week in 52.0% of all the cancer cases. Overall, the agreement on the length of the patient interval was poor (CCC=0.513), but better for patients presenting with alarm symptoms. The agreement was moderate between GP- and patient-reported dates of first presentation (CCC=0.924). CONCLUSION We found that GPs systematically reported a longer patient interval than patients did. We found moderate agreement on reported date of first presentation of symptoms to the GP, meaning that the disagreement in reported patient interval is related to date of first symptom rather than date of first presentation to the GP.

Childhood cancer and factors related to prolonged diagnostic intervals: a Danish population-based study

Background:Early diagnosis of childhood cancer provides hope for better prognoses. Shorter diagnostic intervals (DI) in primary care require better knowledge of the association between presenting symptoms, interpretation of symptoms and the wording of the referral letter.Methods:A Danish nationwide population-based study. Data on 550 children aged <15 years with an incident cancer diagnosis (January 2007–December 2010) were collected through questionnaires to parents (response rate=69%) and general practitioners (GPs) (response rate=87%). The DI from the first presentation in general practice until diagnosis was categorised as short or long based on quartiles. Associations between variables and long DIs were assessed using logistic regression.Results:The GPs interpreted symptoms as ‘vague’ in 25.4%, ‘serious’ in 50.0% and ‘alarm’ in 19.0% of cases. Symptom interpretation varied by cancer type (P<0.001) and was associated with the DI (P<0.001). Vomiting was associated with a shorter DI for central nervous system (CNS) tumours, and pain with a longer DI for leukaemia. Referral letter wording was associated with DI (P<0.001); the shortest DIs were observed when cancer suspicion was raised in the letter.Conclusion:The GPs play an important role in recognising early signs of childhood cancer as their symptom interpretation and referral wording have a profound impact on the diagnostic process.