Diagnostic center for primary care patients with nonspecific symptoms and suspected cancer: compliance to workflow and accuracy of tests and examinations.

OBJECTIVE: To evaluate compliance to workflow and accuracy of tests in Sweden's first fast-track referral pathway for patients with nonspecific symptoms and suspected cancer (SCAN). DESIGN: Prospective cohort study with consecutive inclusion of patients referred to the diagnostic center (DC). SETTING: Patients with nonspecific symptoms were examined in primary care according to a protocol including two test packages and diagnostic imaging. If symptoms were not explained, patients were referred to the DC and a DC-test package was taken. At the DC, further investigations resulted in diagnosis/no diagnosis. SUBJECTS: A total of 290 patients, median age 69 years (interquartile range [IQR] 59-76), 48% men, participated. A total of 64 (22%) were diagnosed with cancer, 186 (64%) with non-malignant disease and 40 (14%) had no new disease. MAIN OUTCOME MEASURE: Compliance was estimated by percentage of compulsory tests taken. Test accuracy was assessed by likelihood ratios (LRs) regarding cancer. RESULTS: A total of 23 (8%) patients had taken both primary care packages, whereas 150 (52%) patients went through entire diagnostic imaging. Abnormal pulmonary X-ray, peak expiratory flow (PEF) and calcium had the highest LRs in primary care (3.5; 3.2; 2.7). A total of 105 (36%) took the complete DC-package, of which bilirubin and cytomegalovirus had the highest LRs (11.5; 10.9). The median number (IQR) of abnormal primary care tests was 5 (3-6) for cancer, 3 (2-6) for other diagnoses and 1 (0-3) for no diagnosis. CONCLUSIONS: Compliance to test packages in primary care was low, which warrants review of the workflow. Few single tests had high accuracy regarding cancer, but the number of abnormal tests can provide guidance in complicated investigations of suspected malignancies.KEY POINTSFast-track referral pathways for patients with nonspecific serious symptoms have been implemented in several countries and are part of the national cancer strategy in all of Scandinavia.Compliance with compulsory tests in primary care was modest in this study; 8% of the patients had taken the entire compulsory test packages.Few single compulsory tests had high accuracy regarding subsequent cancer, which warrants a review of tests and examinations. However, patients diagnosed with cancer had a higher number of abnormal test results compared to the other groups.

Time Intervals Under the Lens at Sweden's First Diagnostic Center for Primary Care Patients With Nonspecific Symptoms of Cancer. A Comparison With Matched Control Patients.

INTRODUCTION: Fast-track referral pathways for patients with nonspecific, serious symptoms have been implemented in several countries. Our objective was to analyze time intervals in the diagnostic routes of patients diagnosed with cancer at Sweden's first Diagnostic Center (DC) for nonspecific symptoms and compare with time intervals of matched control patients. METHODS: Adult patients with nonspecific symptoms that could not be explained by an initial investigation in primary care were eligible for referral to the DC. Patients diagnosed with cancer were matched with patients at another hospital within the same healthcare organization. We aimed for two control patients per DC-patient and matched on tumor type, age and sex. Five time intervals were compared: 1) patient interval (first symptom-primary care contact), 2) primary care interval (first visit-referral to the DC/secondary care), 3) diagnostic interval (first visit-cancer diagnosis), 4) information interval (cancer diagnosis-patient informed) and 5) treatment interval (cancer diagnosis-treatment start). Comparisons between groups and matched cohort analyses were made. RESULTS: Sixty-four patients (22.1%) were diagnosed with cancer at the DC, of which eight were not matchable. Forty-two patients were matched with two controls and 14 were matched with one control. There were no significant differences in patient-, primary care-, or diagnostic intervals between the groups. The information interval was shorter at the DC compared to the control group (difference between matched pairs 7 days, p = 0.001) and the treatment interval was also shorter at the DC with significant differences in the matched analysis (difference between matched pairs 13 days, p = 0.049). The findings remained the same in four sensitivity analyses, made to compensate for differences between the groups. CONCLUSIONS: Up to diagnosis, we could not detect significant differences in time intervals between the DC and the control group. However, the shorter information and treatment intervals at the DC should be advantageous for these patients who will get timely access to treatment or palliative care. Due to limitations regarding comparability between the groups, the results must be interpreted with caution and further research is warranted. TRIAL REGISTRATION: ClinicalTrials.gov-ID: NCT01709539. Registration-date: October 18, 2012.

[Early experience from concentration of cancer care in Sweden]. / Drygt 2 000 har vårdats vid 28 nationella cancerenheter.

Based on an agreement between the Swedish Government and the Swedish Association of Local Authorities and Regions, the Confederation of Regional Cancer Centers was assigned to promote national concentration of highly specialised cancer care. From 2014 to 2018, concentration was implemented regarding treatments in ten different areas. It's too early to evaluate the medical results, but early experience indicates an increased consolidation of care, improved cooperation at the national level, establishment of national multiprofessional conferences and increased adherence to the national guidelines. Need for solutions at national level has been identified e.g. regarding national pricing and IT structure.

Diagnostic spectrum and time intervals in Sweden's first diagnostic center for patients with nonspecific symptoms of cancer.

BACKGROUND: Fast-track referral is an increasingly used method for diagnostic evaluation of patients suspected of having cancer. This approach is challenging and not used as often for patients with only nonspecific symptoms. In order to expedite the diagnostics for these patients, we established Sweden's first Diagnostic Center (DC) focusing on outcomes related to diagnoses and diagnostic time intervals. MATERIAL AND METHODS: The study was designed as a prospective cohort study. Patients aged ≥18 years who presented in primary care with nonspecific symptoms of a serious disease were eligible for referral to the DC after having completed an initial investigation. Acceptable diagnostic time intervals were defined to be a maximum of 15 days in primary care and 22 days at the DC. Diagnostic outcome, length of diagnostic time intervals and patient satisfaction were evaluated. RESULTS: A total of 290 patients were included in the study. Cancer was diagnosed in 22.1%, other diseases in 64.1%, and no diagnosis was identified in 13.8% of these patients. Patients diagnosed with cancer were older, had shorter patient interval (time from first symptom to help-seeking), shorter DC-interval (time from referral decision in primary care to diagnosis) and showed a greater number of symptoms compared to patients with no diagnosis. The median primary care interval was 21 days and the median DC interval was 11 days. Few symptoms, no diagnosis, female sex, longer patient interval, and incomplete investigations were associated with prolonged diagnostic time intervals. Patient satisfaction was high; 86% of patients reported a positive degree of satisfaction with the diagnostic procedures. CONCLUSIONS: We demonstrated that the DC concept is feasible with a diagnosis reached in 86.2% of the patients in addition to favorable diagnostic time intervals at the DC and a high degree of patient satisfaction.

A randomized comparison between league tables and funnel plots to inform health care decision-making.

OBJECTIVE: Comparison of provider performance is commonly used to inform health care decision-making. Little attention has been paid to how data presentations influence decisions. This study analyzes differences in suggested actions by decision-makers informed by league tables or funnel plots. DESIGN: Decision-makers were invited to a survey and randomized to compare hospital performance using either league tables or funnel plots for four different measures within the area of cancer care. For each measure, decision-makers were asked to suggest actions towards 12-16 hospitals (no action, ask for more information, intervene) and provide feedback related to whether the information provided had been useful. SETTING: Swedish health care. PARTICIPANTS: Two hundred and twenty-one decision-makers at administrative and clinical levels. INTERVENTION: Data presentations in the form of league tables or funnel plots. MAIN OUTCOME MEASURES: Number of actions suggested by participants. Proportion of appropriate actions. RESULTS: For all four measures, decision-makers tended to suggest more actions based on the information provided in league tables compared to funnel plots (44% vs. 21%, P < 0.001). Actions were on average more appropriate for funnel plots. However, when using funnel plots, decision-makers more often missed to react even when appropriate. CONCLUSIONS: The form of data presentation had an influence on decision-making. With league tables, decision-makers tended to suggest more actions compared to funnel plots. A difference in sensitivity and specificity conditioned by the form of presentation could also be identified, with different implications depending on the purpose of comparisons. Explanations and visualization aids are needed to support appropriate actions.

Efficient reduction of loco-regional recurrences but no effect on mortality twenty years after postmastectomy radiation in premenopausal women with stage II breast cancer - a randomized trial from the South Sweden Breast Cancer Group.

PURPOSE: To study long term loco-regional and distant recurrence rate and survival after post-mastectomy radiotherapy in combination with oral cyclophosphamide in premenopausal women with stage II breast cancer. STUDY DESIGN: A three-armed randomized multicenter phase III trial comparing 1) Radiotherapy (RT) 2) RT+ oral cyclophosphamide for one year (RT+C) and 3) Oral cyclophosphamide only (C). Radiotherapy was administered, in 20 fractions, to 48Gy to the axilla and parasternal lymph nodes, 45Gy to infra- and supraclavicular fossae and 38Gy to the chest wall. Cyclophosphamide was prescribed as 12 courses of 130mg/m(2) od for 14 days every 4 weeks. PATIENTS AND METHODS: 367 patients from 15 surgical departments in Southern Sweden, representing 80% of all eligible patients, were included in the trial between 1978-1983. Median age was 47 years, median tumour size was 25mm, and 33% of the patients were lymph node negative. Median follow-up time was 24 years. RESULTS: RT reduced the risk at twenty years for loco-regional recurrence in C-treated patients at twenty years with 75% (13.9% vs. 3.5%). The risk reduction was highly significant in both N0 and N+ patients. No reduction in systemic disease or mortality was observed. CONCLUSION: Post-mastectomy radiotherapy reduced loco-regional recurrences in this premenopausal population, but no effect was seen on mortality with 20 years follow-up.

Radiotherapy and tamoxifen after mastectomy in postmenopausal women -- 20 year follow-up of the South Sweden Breast Cancer Group randomised trial SSBCG II:I.

AIMS: To evaluate long-term effects of radiotherapy and tamoxifen after mastectomy on recurrence and survival in stage II breast cancer. METHODS: A randomised phase III study with three treatment alternatives. (1) Radiotherapy 50 Gy/25 fractions to chest wall and regional lymph nodes (RT). (2) Radiotherapy and tamoxifen 30 mg/day for one year (RT+tam) and 3. Tamoxifen (tam). RESULTS: 724 postmenopausal women were included between 1978 and 1985 and the trial was close to population based. Follow-up for survival was 23 years. Locoregional recurrences were reduced from 18.5% in the tam arm to 5.3% in the RT+tam arm. Overall mortality at 20 years was 71% in the RT arm, 68% in the RT+tam arm and 62% in the tam arm. The difference between RT+tam and tam was not significant except in the receptor positive subgroup in favour of non-irradiated patients (p=0.047). The cumulative incidence of systemic disease at 20 years was lower in the RT+Tam arm than in the RT arm, 40% versus 50% (p=0.047). CONCLUSION: Postmastectomy radiotherapy significantly reduced loco-regional recurrences, but overall survival was not improved. At 20 years, a lower mortality was recorded for non-irradiated patients treated with tam.