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      Variation in promptness of presentation among 10,297 patients subsequently diagnosed with one of 18 cancers: Evidence from a National Audit of Cancer Diagnosis in Primary Care

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          Abstract

          Cancer awareness public campaigns aim to shorten the interval between symptom onset and presentation to a doctor (the ‘patient interval’). Appreciating variation in promptness of presentation can help to better target awareness campaigns. We explored variation in patient intervals recorded in consultations with general practitioners among 10,297 English patients subsequently diagnosed with one of 18 cancers (bladder, brain, breast, colorectal, endometrial, leukaemia, lung, lymphoma, melanoma, multiple myeloma, oesophageal, oro-pharyngeal, ovarian, pancreatic, prostate, renal, stomach, and unknown primary) using data from of the National Audit of Cancer Diagnosis in Primary Care (2009–2010). Proportions of patients with ‘prompt’/‘non-prompt’ presentation (0–14 or 15+ days from symptom onset, respectively) were described and respective odds ratios were calculated by multivariable logistic regression. The overall median recorded patient interval was 10 days (IQR 0–38). Of all patients, 56% presented promptly. Prompt presentation was more frequent among older or housebound patients ( p < 0.001). Prompt presentation was most frequent for bladder and renal cancer (74% and 70%, respectively); and least frequent for oro-pharyngeal and oesophageal cancer (34% and 39%, respectively, p <.001). Using lung cancer as reference, the adjusted odds ratios of non-prompt presentation were 2.26 (95% confidence interval 1.57–3.25) and 0.42 (0.34–0.52) for oro-pharyngeal and bladder cancer, respectively. Sensitivity analyses produced similar findings. Routinely recorded patient interval data reveal considerable variation in the promptness of presentation. These findings can help to prioritise public awareness initiatives and research focusing on symptoms of cancers associated with greater risk of non-prompt presentation, such as oro-pharyngeal and oesophageal cancer.

          What's new?

          A critical aspect of cancer diagnosis is how promptly patients consult a doctor after they first notice initial symptoms. Here, the authors examine differences in this so-called patient interval in English patients subsequently diagnosed with one of 18 cancers. On average, patients with bladder and renal cancer as well as older and housebound patients consulted a doctor relatively promptly while patients with oro-pharyngeal and oesophageal cancer took the longest until first presenting to a general practitioner. The authors point out that cancer awareness campaigns should encompass symptoms of oro-pharyngeal and oesophageal cancer aiming to shorten the patient interval for these cancers.

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          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.
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            Sociodemographic factors and delays in the diagnosis of six cancers: analysis of data from the ‘National Survey of NHS Patients: Cancer'

            This paper aims to explore the relationship between sociodemographic factors and the components of diagnostic delay (total, patient and primary care, referral, secondary care) for these six cancers (breast, colorectal, lung, ovarian, prostate, or non-Hodgkin's lymphoma). Secondary analysis of patient-reported data from the ‘National Survey of NHS patients: Cancer' was undertaken (65 192 patients). Data were analysed using univariate analysis and Generalised Linear Modelling. With regard to total delay, the findings from the GLM showed that for colorectal cancer, the significant factors were marital status and age, for lung and ovarian cancer none of the factors were significant, for prostate cancer the only significant factor was social class, for non-Hodgkin's lymphoma the only significant factor was age, and for breast cancer the significant factors were marital status and ethnic group. Where associations between any of the component delays were found, the direction of the association was always in the same direction (female subjects had longer delays than male subjects, younger people had longer delays than older people, single and separated/divorced people had longer delays than married people, lower social class groups had longer delays than higher social class groups, and Black and south Asian people had longer delays than white people). These findings should influence the design of interventions aimed at reducing diagnostic delays with the aim of improving morbidity, mortality, and psychological outcomes through earlier stage diagnosis.
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              Experience of health changes and reasons for delay in seeking care: a UK study of the months prior to the diagnosis of lung cancer.

              The problem of 'delay' in diagnosing cancer as a result of late presentation by individuals who have symptoms, or through doctor or hospital system failures, are currently the subject of close attention as part of broader initiatives to reduce deaths from cancer. However, in lung cancer there has been a generally held view that 'late' diagnosis is inevitable because of the biomedical difficulties in detecting the disease at an early stage. Data about events recalled prior to diagnosis from an interview study with 22 individuals recently diagnosed with operable (early stage) and inoperable (late stage) lung cancer are reported. Findings reveal that individuals, regardless of their disease stage, or their social background failed to recognise symptoms that they experienced over many months prior to their eventual diagnosis as serious and warranting medical attention. Symptoms, even when severe, were instead attributed to everyday causes and were not interpreted as indicative of ill-health. There was a reluctance to seek help for symptoms among some because they were unsure whether what they were experiencing was normal or not, and in one case because as a smoker, the individual felt 'unworthy' of medical care. This study suggests that previous assumptions that focus on individual or psychological factors in the processes of delay in cancer diagnosis need revisiting and the broader social influences that may affect the timing of diagnosis among people with lung cancer should be considered.
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                Author and article information

                Journal
                Int J Cancer
                Int. J. Cancer
                ijc
                International Journal of Cancer. Journal International du Cancer
                BlackWell Publishing Ltd (Oxford, UK )
                0020-7136
                1097-0215
                01 September 2014
                25 February 2014
                : 135
                : 5
                : 1220-1228
                Affiliations
                [1 ]Cambridge Centre for Health Services Research, University of Cambridge Cambridge, United Kingdom
                [2 ]National Cancer Intelligence Network (NCIN), Public Health England London, United Kingdom
                [3 ]Primary Care Unit, University of Cambridge Cambridge, United Kingdom
                [4 ]North Wales Centre for Primary Care Research, College of Health and Behavioural Sciences, Bangor University Wrexham, United Kingdom
                [5 ]Wolfson Research Institute, School of Medicine and Health, University of Durham, Queen's Campus, University Boulevard Stockton-on-Tees, United Kingdom
                Author notes
                Correspondence to: Georgios Lyratzopoulos, Strangeways Research Laboratory, Worts' Causeway, Cambridge CB1 8RN, United Kingdom, Tel.: +44-1223-330326, E-mail: gl290@ 123456medschl.cam.ac.uk

                Grant sponsor: NHS Public Health Training Scheme in the East of England; Grant sponsor: National Institute for Health Research; Grant number: PDF-2011-04-047

                Article
                10.1002/ijc.28763
                4277322
                24515930
                e8b2d525-3a95-450e-a490-df3c2d5976ca
                © 2014 The Authors. Published by Wiley Periodicals, Inc. on behalf of UICC.

                This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.

                History
                : 28 October 2013
                : 09 June 2014
                Categories
                Epidemiology

                Oncology & Radiotherapy
                cancer,patient interval,promptness,presentation,delay,oro-pharyngeal,oesophageal,bladder,renal,variation

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