Cancer suspicion, referral to cancer patient pathway and primary care interval: a survey and register study exploring 10 different types of abdominal cancer.

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.

This study investigates how often a suspicion of cancer is raised by the general practitioner (GP) at the first consultation leading up to a diagnosis for several abdominal cancer types. The study also explores how often the GPs refer these patients to a cancer patient pathway (CPP). Moreover, the length of the primary care interval is measured, that is, the interval from the first time when the patient presents with symptoms to their GP until referral to a hospital or another specialist. The results show that the GPs initially suspected cancer or other serious disease in 46­78% of 10 selected types of abdominal cancer; lowest suspicion was seen for kidney cancer, and referred 35­65% to a CPP; lowest CPP use was seen for oesophageal cancer. The median time from the first visit to the GP until referral to a hospital or another specialist was 0­11 days, depending on the cancer type. The most important factor for a prompt referral was the GP's initial cancer suspicion; this was seen independent of the diagnosed cancer type. These findings call for the development of new cancer pathways that better target the patients in whom the GP does not initially suspect cancer.

Ovarian cancer stage, variation in transvaginal ultrasound examination rates and the impact of an urgent referral pathway: A national ecological cohort study.

INTRODUCTION: The aim of this study was to determine whether variation in transvaginal ultrasound examination rates in Danish general practice populations is associated with ovarian cancer outcomes, and to explore the impact of the introduction of a cancer patient pathway for ovarian cancer. MATERIAL AND METHODS: We performed a national register-based cohort study of gynecological cancer-free women aged 40 years or above, living in Denmark and listed with a specific general practitioner in 2004-2014. Practice populations were divided into quartiles according to the general practitioners' transvaginal ultrasound propensity in the preceding year. Associations between transvaginal ultrasound rates and ovarian cancer outcomes were analyzed using Poisson and logistic regression. RESULTS: We included 2769 general practices with 1 739 422 listed women, of whom 5325 were diagnosed with ovarian cancer during the study period. Practices varied twofold in transvaginal ultrasound rates before and after the implementation of the cancer patient pathway. Before the cancer patient pathway was introduced, women listed with practices with the highest transvaginal ultrasound rates were diagnosed with earlier stages of ovarian cancer (odds ratio 1.38, 95% confidence interval 1.06 to 1.81) and had a higher proportion of borderline tumors (incidence rate ratio 1.38, 95% confidence interval 1.10 to 1.75) compared with women least exposed to transvaginal ultrasound. After the cancer patient pathway, no significant differences were identified between the groups. CONCLUSIONS: Before the cancer patient pathway, women exposed most to transvaginal ultrasound were significantly more likely to be diagnosed with early stage ovarian cancer compared with those least exposed to transvaginal ultrasound. After the cancer patient pathway was implemented, the difference disappeared. This suggests that increased awareness and access to transvaginal ultrasound is useful for diagnosing early-stage ovarian cancer.

Advanced-stage cancer and time to diagnosis: An International Cancer Benchmarking Partnership (ICBP) cross-sectional study.

OBJECTIVE: To investigate the relationship between tumour stage at diagnosis and selected components of primary and secondary care in the diagnostic interval for breast, colorectal, lung and ovarian cancers. METHODS: Observational study based on data from 6,162 newly diagnosed symptomatic cancer patients from Module 4 of the International Cancer Benchmarking Partnership. We analysed the odds of advanced stage of cancer as a flexible function of the length of primary care interval (days from first presentation to referral) and secondary care interval (days from referral to diagnosis), respectively, using logistic regression with restricted cubic splines. RESULTS: The association between time intervals and stage was similar for each type of cancer. A statistically significant U-shaped association was seen between the secondary care interval and the diagnosis of advanced rather than localised cancer, odds decreasing from the first day onwards and increasing around three and a half months. A different pattern was seen for the primary care interval, flat trends for colorectal and lung cancers and a slightly curved association for ovarian cancer, although not statistically significant. CONCLUSION: The results confirm previous findings that some cancers may progress even within the relatively short time frame of regulated diagnostic intervals. The study supports the current emphasis on expediting symptomatic diagnosis of cancer.

Ovarian cancer suspicion, urgent referral and time to diagnosis in Danish general practice: a population-based study.

BACKGROUND: Ovarian cancer (OC) survival rates are lower in Denmark than in countries with similar health care. Prolonged time to diagnosis could be a contributing factor. The Danish cancer patient pathway (CPP) for OC was introduced in 2009. It provides GPs with fast access to diagnostic work-up. OBJECTIVE: To investigate cancer suspicion and pathway use among GPs and to explore the association between these factors and the diagnostic intervals (DIs). METHODS: We conducted a national population-based cohort study using questionnaires and national registers. RESULTS: Of the 313 women with participating GPs, 91% presented with symptoms within 1 year of diagnosis, 61% presented vague non-specific symptoms and 62% were diagnosed with late-stage disease. Cancer was suspected in 39%, and 36% were referred to a CPP. Comorbidity [prevalence ratio (PR): 0.53, 95% confidence interval (CI): 0.29-0.98] and no cancer suspicion (PR: 0.35, 95% CI: 0.20-0.60) were associated with no referral to a CPP. The median DI was 36 days. Long DIs were associated with no cancer suspicion (median DI: 59 versus 20 days) and no referral to a CPP (median DI: 42 versus 23 days). CONCLUSIONS: Nine in ten patients attended general practice with symptoms before diagnosis. Two-thirds initially presented with vague non-specific symptoms were less likely to be referred to a CPP and had longer DIs than women suspected of cancer. These findings underline the importance of supplementing the CPP with additional accelerated diagnostic routes.