Cancer suspicion in general practice, urgent referral and time to diagnosis: a population-based GP survey and registry study

BMC Cancer

Henry Jensen²  Marie Louise Tørring¹  Frede Olesen¹  Jens Overgaard³  Peter Vedsted¹ 

[1] Research Unit for General Practice, Research Centre for Cancer Diagnosis in Primary Care, Department of Public Health, Aarhus University, Bartholins Allé 2, DK-8000 Aarhus C, Denmark

[2] Section for General Medical Practice, Department of Public Health, Aarhus University, Bartholins Allé 2, DK-8000 Aarhus C, Denmark

[3] Department of Experimental Clinical Oncology, Aarhus University Hospital, Noerrebrogade, DK-8000 Aarhus C, Denmark

关键词: Denmark;    Cancer suspicion;    Delay;    General practice;    (Early) diagnosis;    Neoplasm;    Fast-track;   

Others  :  1121186
DOI  :  10.1186/1471-2407-14-636

 received in 2014-05-27, accepted in 2014-08-26,  发布年份 2014

【 摘 要 】

Background

Many countries have implemented standardised cancer patient pathways (CPPs) to ensure fast diagnosis of patients suspected of having cancer. Yet, studies are sparse on the impact of such CPPs, and few have distinguished between referral routes. For incident cancer patients, we aimed to determine how often GPs suspected cancer at the time of first presentation of symptoms in general practice and to describe the routes of referral for further investigation. In addition, we aimed to analyse if the GP’s suspicion of cancer could predict the choice of referral to a CPP. Finally, we aimed to analyse associations between not only cancer suspicion and time to cancer diagnosis, but also between choice of referral route and time to cancer diagnosis.

Methods

We conducted a population-based, cross-sectional study of incident cancer patients in Denmark who had attended general practice prior to their diagnosis of cancer. Data were collected from GP questionnaires and national registers. We estimated the patients’ chance of being referred to a CPP (prevalence ratio (PR)) using Poisson regression. Associations between the GP’s symptom interpretation, use of CPP and time to diagnosis were estimated using quantile regression.

Results

5,581 questionnaires were returned (response rate: 73.8%). A GP was involved in diagnosing the cancer in 4,101 (73.5%) cases (3,823 cases analysed). In 48.2% of these cases, the GP interpreted the patient’s symptoms as ‘alarm’ symptoms suggestive of cancer. The GP used CPPs in 1,426 (37.3%) cases. Patients, who had symptoms interpreted as ‘vague’ had a lower chance of being referred to a CPP than when interpreted as ‘alarm’ symptoms (PR = 0.53 (95%CI: 0.48;0.60)). Patients with ‘vague’ symptoms had a 34 (95% CI: 28;41) days longer median time to diagnosis than patients with ‘alarm’ symptoms.

Conclusions

GPs suspect cancer more often than they initiate a CPP, and patients were less likely to be referred to a CPP when their symptoms were not interpreted as alarm symptoms of cancer. The GP’s choice of referral route was a strong predictor of the duration of the diagnostic interval, but the GP’s symptom interpretation was approximately twice as strong an indicator of a longer diagnostic interval.

【 授权许可】

   
2014 Jensen et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

【 参考文献 】

• [1]Prades J, Espinas JA, Font R, Argimon JM, Borras JM: Implementing a Cancer Fast-track Programme between primary and specialised care in Catalonia (Spain): a mixed methods study. Br J Cancer 2011, 105:753-759.
• [2]Probst HB, Hussain ZB, Andersen O: Cancer patient pathways in Denmark as a joint effort between bureaucrats, health professionals and politicians-A national Danish project. Health Policy 2012, 105:65-70.
• [3]Olesen F, Hansen RP, Vedsted P: Delay in diagnosis: the experience in Denmark. Br J Cancer 2009, 101:S5-S8.
• [4]Toustrup K, Lambertsen K, Birke-Sorensen H, Ulhoi B, Sorensen L, Grau C: Reduction in waiting time for diagnosis and treatment of head and neck cancer - a fast track study. Acta Oncol 2011, 50:636-641.
• [5]Vallverdu-Cartie H, Comajuncosas-Camp J, Orbeal-Saenz RA, Lopez-Negre JL, Gris Garriga PJ, Jimeno-Fraile J, Hermoso-Bosch J, Sanchez-Pradell C, Torra-Alsina S, Urgelles-Bosch J, Pares D: Results of implementation of a fast track pathway for diagnosis of colorectal cancer. Rev Esp Enferm Dig 2011, 103:402-407.
• [6]Valentin-Lopez B, Ferrandiz-Santos J, Blasco-Amaro JA, Morillas-Sainz JD, Ruiz-Lopez P: Assessment of a rapid referral pathway for suspected colorectal cancer in Madrid. Fam Pract 2012, 29:182-188.
• [7]Department of Health: The NHS Cancer Plan. A plan for investment, A plan for reform. London: Department of Health; 2000.
• [8]Baughan P, O’Neill B, Fletcher E: Auditing the diagnosis of cancer in primary care: the experience in Scotland. Br J Cancer 2009, 101(2):S87-S91.
• [9]Potter S, Govindarajulu S, Shere M, Braddon F, Curran G, Greenwood R, Sahu AK, Cawthorn SJ: Referral patterns, cancer diagnoses, and waiting times after introduction of two week wait rule for breast cancer: prospective cohort study. BMJ 2007, 335:288.
• [10]Jones R, Rubin G, Hungin P: Is the two week rule for cancer referrals working? BMJ 2001, 322:1555-1556.
• [11]Neal RD, Allgar VL, Ali N, Leese B, Heywood P, Proctor G, Evans J: Stage, survival and delays in lung, colorectal, prostate and ovarian cancer: comparison between diagnostic routes. Br J Gen Pract 2007, 57:212-219.
• [12]Elliss-Brookes L, McPhail S, Ives A, Greenslade M, Shelton J, Hiom S, Richards M: Routes to diagnosis for cancer - determining the patient journey using multiple routine data sets. Br J Cancer 2012, 107:1220-1226.
• [13]Allgar VL, Neal RD, Ali N, Leese B, Heywood P, Proctor G, Evans J: Urgent GP referrals for suspected lung, colorectal, prostate and ovarian cancer. Br J Gen Pract 2006, 56:355-362.
• [14]The National Board of Health: National Cancer Plan II • Denmark National Board of Health recommendations for improving cancer healthcare services. Copenhagen: The National Board of Health; 2005.
• [15]Svendsen RP, Stovring H, Hansen BL, Kragstrup J, Sondergaard J, Jarbol DE: Prevalence of cancer alarm symptoms: A population-based cross-sectional study. Scand J Prim Health Care 2010, 28:132-137.
• [16]Jones R, Charlton J, Latinovic R, Gulliford M: Alarm symptoms and identification of non-cancer diagnoses in primary care: cohort study. BMJ 2009, 339:1-9.
• [17]Jones R, Latinovic R, Charlton J, Gulliford MC: Alarm symptoms in early diagnosis of cancer in primary care: cohort study using General Practice Research Database. BMJ 2007, 334:1040.
• [18]Neal RD, Din NU, Hamilton W, Ukoumunne OC, Carter B, Stapley S, Rubin G: Comparison of cancer diagnostic intervals before and after implementation of NICE guidelines: analysis of data from the UK General Practice Research Database. Br J Cancer 2014, 110:584-592.
• [19]Scheel BI, Ingebrigtsen SG, Thorsen T, Holtedahl K: Cancer suspicion in general practice: the role of symptoms and patient characteristics, and their association with subsequent cancer. Br J Gen Pract 2013, 63:627-635.
• [20]Ingebrigtsen SG, Scheel BI, Hart B, Thorsen T, Holtedahl K: Frequency of ‘warning signs of cancer’ in Norwegian general practice, with prospective recording of subsequent cancer. Fam Pract 2013, 30:153-160.
• [21]Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM: GLOBOCAN 2008, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 10. Lyon: International Agency for Research on Cancer; 2012.
• [22]Andersen JS, Olivarius NF, Krasnik A: The Danish National Health Service Register. Scand J Public Health 2011, 39:34-37.
• [23]Larsen MB, Jensen H, Hansen RP, Olesen F, Vedsted P: Identification of patients with incident cancers using administrative registry data. Dan Med J 2014, 61:A4777.
• [24]Lynge E, Sandegaard JL, Rebolj M: The Danish National Patient Register. Scand J Public Health 2011, 39:30-33.
• [25]Gjerstorff ML: The Danish Cancer Registry. Scand J Public Health 2011, 39:42-45.
• [26]Weller D, Vedsted P, Rubin G, Walter FM, Emery J, Scott S, Campbell C, Andersen RS, Hamilton W, Olesen F, Rose P, Nafees S, van Rijswijk E, Hiom S, Muth C, Beyer M, Neal RD: The Aarhus statement: improving design and reporting of studies on early cancer diagnosis. Br J Cancer 2012, 106:1262-1267.
• [27]The National Board of Health: Det moderniserede Cancerregister - metode og kvalitet [In Danish]. Copenhagen: The National Board of Health; 2009.
• [28]Pedersen CB: The Danish Civil Registration System. Scand J Public Health 2011, 39:22-25.
• [29]Quan H, Li B, Couris CM, Fushimi K, Graham P, Hider P, Januel JM, Sundararajan V: Updating and validating the Charlson comorbidity index and score for risk adjustment in hospital discharge abstracts using data from 6 countries. Am J Epidemiol 2011, 173:676-682.
• [30]Thygesen LC, Daasnes C, Thaulow I, Bronnum-Hansen H: Introduction to Danish (nationwide) registers on health and social issues: structure, access, legislation, and archiving. Scand J Public Health 2011, 39:12-16.
• [31]UNESCO: International Standard Classification of Education ISCED 2011. Montreal, Quebec, Canada: UNESCO; 2012.
• [32]Statistics Denmark: Quality Declarations. http://dst.dk/en/Statistik/dokumentation/Declarations.aspx webcite
• [33]Jensen H, Torring ML, Larsen MB, Vedsted P: Existing data sources for clinical epidemiology: Danish Cancer in Primary Care (CaP) cohort. Clin Epidemiol 2014, 6:237-246.
• [34]Ferlay J, Steliarova-Foucher E, Lortet-Tieulent J, Rosso S, Coebergh JW, Comber H, Forman D, Bray F: Cancer incidence and mortality patterns in Europe: estimates for 40 countries in 2012. Eur J Cancer 2013, 49:1374-1403.
• [35]Barros AJ, Hirakata VN: Alternatives for logistic regression in cross-sectional studies: an empirical comparison of models that directly estimate the prevalence ratio. BMC Med Res Methodol 2003, 3:21. BioMed Central Full Text
• [36]Miranda A: QCOUNT: Stata program to fit quantile regression models for count data. Boston: Boston College Department of Economics; 2006.
• [37]Hao N: Quantile regression. Thousand Oaks, Calif: Sage Publications; 2007.
• [38]Machado JA, Santos Silva JMC: Quantiles for Counts. J Am Stat Assoc 2005, 100:1225-1237.
• [39]Davies RJ, Ewings P, Welbourn R, Collins C, Kennedy R, Royle C: A prospective study to assess the implementation of a fast-track system to meet the two-week target for colorectal cancer in Somerset. Colorectal Dis 2002, 4:28-30.
• [40]Dwivedi AK, Dwivedi SN, Deo S, Shukla R, Pandey A, Dwivedi DK: An Epidemiological study on delay in treatment initiation of cancer patients. Health 2012, 4:66-79.
• [41]Hansen RP, Vedsted P, Sokolowski I, Sondergaard J, Olesen F: Time intervals from first symptom to treatment of cancer: a cohort study of 2,212 newly diagnosed cancer patients. BMC Health Serv Res 2011, 11:284. BioMed Central Full Text
• [42]Murchie P, Campbell NC, Delaney EK, Dinant GJ, Hannaford PC, Johansson L, Lee AJ, Rollano P, Spigt M: Comparing diagnostic delay in cancer: a cross-sectional study in three European countries with primary care-led health care systems. Fam Pract 2012, 29:69-78.