̽��ֱ�� of Cambridge - Georgios Lyratzopoulos

Diagnosis of cancer as a medical emergency leads to poorer prognosis for many patients

cjb250 — Tue, 11 Oct 2016 11:00:55 +0000

In an article in the journal Nature Reviews Clinical Oncology, a team of researchers jointly led by the ̽��ֱ�� of Cambridge and ̽��ֱ�� College London reviewed current evidence from 26 peer-reviewed studies and 6 online reports from 7 countries. ̽��ֱ��evidence indicates that emergency diagnosis of cancer is a universal problem, challenging previous assumptions regarding this issue being a particular problem only in the UK.

Looking at prognosis alone, the researchers reviewed evidence that showed that patients diagnosed with colorectal cancer at emergency presentation had a 50% one year survival rate, compared to 82% for patients diagnosed electively - in other words, following a GP referral to a specialist. Similarly, for lung cancer the respective survival rates were 12% versus 40%. This was in part because cancer diagnosed at emergency care was more likely to be at an advanced stage. However, this was not the full story: even when patients presented with tumours of the same disease stage they still had a worse prognosis if they were diagnosed in emergency care, possibly because of problems in the quality of their management out-of-hours, or because they have more aggressive disease on a stage-for-stage basis.

In the UK, about three in 10 emergency presenters are referred to hospital emergency services by their family doctors, but others self-present to accident and emergency departments. Patients at both ends of the age spectrum – the youngest and the oldest – were most likely to have their cancer diagnosed in emergency contexts. Differences between genders were unclear – and vary for different types of cancer.

However, the review found particular inequalities between socioeconomic groups. Although the evidence came only from studies looking at colorectal and lung cancer, it found that people from more deprived backgrounds were at a greater risk of being diagnosed at emergency care. ̽��ֱ��same was true for people of Asian ethnicity in the UK and African-Americans in the USA.

First author Dr Yin Zhou from the Primary Care Unit at the ̽��ֱ�� of Cambridge, who led the study, says: " ̽��ֱ��earlier an individual can get a diagnosis of cancer, the better the prognosis and the options for treatment. When the first time their cancer is identified is when it becomes an emergency, the prognosis is much worse.”

Dr Georgios Lyratzopoulos, who instigated and coordinated the collaboration, based at the Department of Epidemiology and Public Health, ̽��ֱ�� College London adds: "A substantial minority of cancer patients who are diagnosed as emergencies do not seem to have had prior contact with the formal healthcare system; we need to find out why they are not seeking medical help sooner. Is it because they are unaware of any symptoms until too late, or is it because they do not think the symptoms are a sign of a more serious problem?"

̽��ֱ��researchers found that the evidence points towards developing new screening methods and improving participation in existing screening programme as one possible way to reduce emergency presentations in the medium to longer term. For example, based on indirect evidence in one geographical region in the UK, the introduction of faecal occult blood test in the UK is likely to have reduced the proportion of patients with colorectal cancer diagnosed as emergencies by half between 1999 and 2004.

"What was clear from our review," adds Dr Zhou, "is how little data there is available about emergency diagnoses. What little data there is suggests that we're only seeing the tip of the iceberg and that this could be a much bigger problem, particularly in low and middle income countries."

A major part of the global evidence on emergency presentations (in terms of patient numbers) relates to English patients – thanks to the pioneering Routes to Diagnosis project and population-based data collected by the National Cancer Registration and Analysis Services of Public Health England.

Dr Anne Mackie, Director of Screening at Public Health England, said: “Screening has a vital role to play in identifying cancers at an early stage and getting people the right treatment as soon as possible, with better survival chances. Screening is always the person’s own choice and they should speak to their GP if they have any questions before deciding if screening is right for them.”

Reference
Zhou, Y et al. Diagnosis of cancer as an emergency: a critical review of current evidence. Nature Reviews Clinical Oncology; 11 Oct 2016; 10.1038/nrclinonc.2016.155

Too many patients – particularly those from disadvantaged backgrounds – are being diagnosed with cancer as medical emergencies, say researchers. This means that their chances of successful treatment are greatly reduced.

̽��ֱ��earlier an individual can get a diagnosis of cancer, the better the prognosis and the options for treatment. When the first time their cancer is identified is when it becomes an emergency, the prognosis is much worse

Yin Zhou

Lydia

Accident & Emergency Sign

̽��ֱ��text in this work is licensed under a Creative Commons Attribution 4.0 International License. For image use please see separate credits above.

Yes

Licence type:

Attribution

Cancer patients lose faith in healthcare system if referred late by GP

Anonymous — Fri, 31 Jul 2015 08:25:08 +0000

̽��ֱ��results are based on further analysis of survey data from more than 70,000 cancer patients, by Cancer Research UK scientists at the ̽��ֱ�� of Cambridge and ̽��ֱ�� College London, published today in the European Journal of Cancer Care.

Of the nearly 60,000 survey respondents diagnosed through their GP, almost a quarter (23 per cent) had been seen three or more times before being referred for cancer tests.

Four in ten (39 per cent) of those who had experienced referral delays were dissatisfied with the support they received from their GP compared to just under three in ten (28 per cent) of those referred after one or two GP visits.

Overall, patients who had seen their GP three or more times before being referred were more likely to report negative experiences across 10 of 12 different aspects of their care. For example, 18 per cent of these patients were dissatisfied with the way they were told they had cancer, compared to 14 per cent among those who were referred more quickly.

Four in ten expressed dissatisfaction with how hospital staff and their GP had worked with each other to provide the best possible care, compared to one in three among those referred promptly.

Dissatisfaction with the overall care received was even higher among the just under one in ten (9 per cent) patients who saw their GP five or more times before being referred.

Study author Dr Georgios Lyratzopoulos, from the Department of Public Health and Primary Care at the ̽��ֱ�� of Cambridge, said: “This research shows that first impressions go a long way in determining how cancer patients view their experience of cancer treatment. A negative experience of diagnosis can trigger loss of confidence in their care throughout the cancer journey.

“When they occur, diagnostic delays are largely due to cancer symptoms being extremely hard to distinguish from other diseases, combined with a lack of accurate and easy-to-use tests. New diagnostic tools to help doctors decide which patients need referring are vital to improve the care experience for even more cancer patients.”

Dr Richard Roope, Cancer Research UK’s GP expert, said: “It’s vital we now step up efforts to ensure potential cancer symptoms can be investigated promptly, such as through the new NICE referral guidelines launched last month to give GPs more freedom to quickly refer patients with worrying symptoms. This will hopefully contribute to improving the patient experience, one of the six strategic priorities recommended by the UK’s Cancer Task Force last week.”

Reference

Mendonca S.C. et al, Pre-referral general practitioner consultations and subsequent experience of cancer care: evidence from the English Cancer Patient Experience Survey, European Journal of Cancer (2015)

Adapted from a press release by Cancer Research UK.

If it takes more than three trips to the GP to be referred for cancer tests, patients are more likely to be dissatisfied with their overall care, eroding confidence in the doctors and nurses who go on to treat and monitor them, according to new research.

This research shows that first impressions go a long way in determining how cancer patients view their experience of cancer treatment

Georgios Lyratzopoulos

Jason Parks

Impatiently Waiting

̽��ֱ��text in this work is licensed under a Creative Commons Attribution 4.0 International License. For image use please see separate credits above.

Yes

Licence type:

Attribution-Noncommerical

Patients with mouth and oesophageal cancers take longer to seek help from GP

jfp40 — Tue, 11 Feb 2014 16:28:05 +0000

Lack of awareness of the symptoms of mouth and oesophageal cancer means people take much longer to talk to their GPs about these, compared with other, cancers.

New research from Cambridge, Durham and Bangor found that people with mouth cancer wait for around a month after first spotting symptoms before visiting their GP, and those with oesophageal cancer around three weeks.

Patients with bladder and kidney cancer, however, wait only two or three days before reporting their symptoms to a doctor.

Published in the International Journal of Cancer, the study drew on data from the National Audit of Cancer Diagnosis in Primary Care and included GP consultations with more than 10,000 patients with 18 different cancer types.

Mouth and oesophageal cancer are relatively common, but both have a relatively poor outlook for survival.

“Previous research shows that two of the key symptoms for these cancers – difficulty swallowing and ulcers that don’t heal – are the least well-known by the public for their links with cancer,” explained the ̽��ֱ�� of Cambridge’s Dr Georgios Lyratzopoulos, one of the authors of the study.

Their results suggest more needs to be done to raise awareness of these symptoms. According to Sara Hiom, Cancer Research UK’s director of early diagnosis: “It’s good to see patients with kidney and bladder cancers going to their doctors so quickly, perhaps because their symptoms are more noticeable. But we must do more to encourage people with other less well recognised symptoms to see their GPs as soon as possible.

“Some symptoms are more obvious than others so the important thing is to get to know your own body and what’s normal for you. When cancer is diagnosed earlier, treatment is usually more effective and the chances of beating the disease are higher.”

̽��ֱ��NHS ‘Be Clear on Cancer’ campaigns do not currently include symptoms of mouth cancer.

New research shows that lack of awareness of the symptoms of mouth and oesophageal cancer means people wait much longer before visiting their GPs than people with symptoms of other cancers.

Two of the key symptoms for these cancers – difficulty swallowing and ulcers that don’t heal – are the least well-known by the public for their links with cancer

Dr Georgios Lyratzopoulos

eyesnightclosed

Throat ulcer

This work is licensed under a Creative Commons Licence. If you use this content on your site please link back to this page.

Yes

Licence type:

Attribution

Awareness could eliminate inequalities in cancer diagnoses

gm349 — Tue, 13 Nov 2012 15:13:33 +0000

There are substantial inequalities in the stage at which cancer patients receive their diagnosis – a critical factor for cancer survival – a new study by the ̽��ֱ�� of Cambridge reveals. ̽��ֱ��researchers found that age, sex and income as well as the type of cancer influenced the risk of a patient being diagnosed at an advanced stage of the disease. Eliminating these inequalities would help improve the chances of a cure for up to 5,600 patients with seven common cancers each year. ̽��ֱ��research was published today in the Annals of Oncology.

̽��ֱ��scientists studied ten common types of cancer responsible for two-thirds of all new cancer diagnoses in England. They found that 5,600 patients with seven common cancers each year are diagnosed at a late stage of their illness because of inequalities.

Narrowing social differences in stage at diagnosis could benefit 2000 men with prostate cancer, 1300 patients with lung cancer, 1000 women with breast cancer and 700 patients with melanoma, who are currently diagnosed in advanced stage because of inequalities. There are also important potential gains for patients with three rarer cancers (endometrial, kidney and bladder cancer). During the study period, 2006-2010, there were no notable social inequalities in the risk of advanced stage at diagnosis for patients with bowel (colon or rectal) cancer and women with ovarian cancer.

̽��ֱ��research shows that 1 out of every 9 patients with these seven cancers who are currently diagnosed in advanced stage could be diagnosed at an earlier stage. Most of the improvements seem to be achievable by better educating people about symptoms and signs of potential cancer that should prompt a consultation with a doctor.

“We know that earlier stage diagnosis of cancer is important – it dramatically improves the effectiveness of treatment and survival for many cancers,” said lead author Dr Georgios Lyratzopoulos, a researcher of the ̽��ֱ�� of Cambridge. “This study highlights the importance of awareness of cancer symptoms and how people of different social groups react to such symptoms. It provides evidence about which patient groups would benefit most from targeted campaigns to raise awareness of different cancers.”

For the study, Cambridge researchers worked together with the NHS to examine data from the Eastern Cancer Registration and Information Centre (ECRIC), the English regional cancer registry with the most complete information on stage at diagnosis. (Statistics about the stage of diagnosis of common cancers has been difficult to come by in the past, but their availability is currently increasing across the UK.)

̽��ֱ��investigators examined information on the stage at diagnosis of nearly 100,000 patients with any of ten different cancers, including the five most common cancers (lung, breast, prostate, colon and rectal cancer) and also bladder, kidney, ovarian, and endometrial cancer and melanoma (the most aggressive type of skin cancer). ̽��ֱ��analysis took account of different tumour sub-types and whether the cancer was detected through screening.

̽��ֱ��potential for improving diagnosis was not the same across all cancers. Men with melanoma and lung cancer were more likely to be diagnosed at an advanced stage compared with women with the same cancer. Patients with breast, prostate and endometrial cancer and melanoma living in poorer neighbourhoods were more likely to be diagnosed at late stage compared with those living in less deprived neighbourhoods.

̽��ֱ��researchers focused on examining variation in diagnosis by age among patients aged 65 or older, because 2/3 of all cancers occur in this age group and because of evidence of potential deficits in the care of older patients. They found that for four cancers (breast, prostate, melanoma and endometrial) older patients were more likely to be diagnosed at an advanced stage. However, for three other cancers (lung, bladder and renal cancer) the opposite was true, with older patients being less likely to be diagnosed at an advanced stage.

“For cancers where there is evidence that symptom awareness matters, such as breast, prostate, melanoma and endometrial cancer, older individuals are more likely to have their cancer discovered late. In contrast, for cancers which there is a good enough medical test, such as X-ray or ultrasound, it seems that being old can protect somewhat from late stage diagnosis – presumably because the frequency of having these tests increases with older age and infirmity,” said Dr Lyratzopoulos.

Policy experts believe that deficiencies in both early diagnosis and optimal treatment may be responsible for poorer cancer survival in the UK compared with some other European countries with similar health care systems and robust statistics (e.g. Scandinavian countries). Regarding deficiencies in early diagnosis, delays in patients recognising symptoms and presenting to their doctors as well as delays by the health system could be responsible. ̽��ֱ��study highlights that differences in perceptions of cancer between patients may be more important than previously thought for at least some (although not all) types of cancer.

“Awareness campaigns about the symptoms of bowel and ovarian cancer have been launched relatively recently and future research should establish their effectiveness. Avoiding a patchy dissemination of awareness messages among different social groups is important to prevent future inequalities in early diagnosis and for such campaigns to have the maximum impact,” said senior author Dr David Greenberg from ECRIC (the Eastern Cancer Registration and Information Centre).

̽��ֱ��study was supported by the National Institute for Health Research and ECRIC.

Each year 5,600 patients are diagnosed with cancer at a late stage because of inequalities. Study underlines importance of awareness campaigns.

We know that earlier stage diagnosis of cancer is important – it dramatically improves the effectiveness of treatment and survival for many cancers.

lead author Dr Georgios Lyratzopoulos

flickr from GE Healthcare

Cancer

This work is licensed under a Creative Commons Licence. If you use this content on your site please link back to this page.

Yes

Study examines number of GP visits before cancer patients are referred to specialists

gm349 — Fri, 24 Feb 2012 14:23:57 +0000

More than three quarters (77%) of cancer patients who first present to their family doctors (GPs) with suspicious symptoms are referred to hospital after only one or two consultations, a new study has found. However, the new research also shows a wide variation in the number of times a cancer patient sees their general practitioner before they are referred to a specialist, with the most pre-referral consultations occurring when the cancer was one of the less common types, or when the patient was either female, young, or an older person from an ethnic minority. ̽��ֱ��research was published today, 24 February, in the journal ̽��ֱ��Lancet Oncology.

̽��ֱ��study, led by researchers at the ̽��ֱ�� of Cambridge, found that patients with breast, melanoma, testicular and endometrial cancers are more likely to be referred to a specialist after just one or two consultations. However, patients with some less common cancers such as multiple myeloma, pancreatic, stomach and ovarian cancer, as well as patients with lung and colon cancers and lymphomas are more likely to require three or more visits to their family doctor before they are referred to a hospital specialist. Patients with multiple myeloma, a blood cancer that is notoriously difficult to diagnose since it mimics many other conditions, are 18 times more likely to require three or more pre-referral consultations compared with patients with breast cancer.

“These findings highlight limitations in current scientific knowledge about these cancers,” said lead investigator Dr Georgios Lyratzopoulos, Clinical Senior Research Associate at the ̽��ֱ�� of Cambridge. “Medical research in recent decades has prioritised improving cancer treatments, but knowledge about the ‘symptom signature’ of common cancers and practical solutions on how best to diagnose them is still emerging. Hopefully, our study will stimulate investment into research, focusing on patients with cancers and characteristics where the potential to improve the experience of diagnosis of cancer is greatest.”

̽��ֱ��researchers have also found that the diagnosis of cancer is more challenging among young patients, women, and older ethnic minority patients – all of these three groups are known to have a lower risk of developing cancer compared with older, male and white patients in the United Kingdom.

These findings amplify similar patterns first reported by co-author Dr Richard Neal, Senior Lecturer in General Practice at Bangor ̽��ֱ��, among cancer patients who took part in a similar survey that was carried out in 2000. Dr Neal said: “ ̽��ֱ��fact that the diagnosis of cancer may be more challenging in some patient groups and for some cancers can help us to tailor diagnostic efforts. ̽��ֱ��findings will also inform the forthcoming update of the NICE Guidelines for Referral of Suspected Cancer, which will have an important impact on policy and practice.”

̽��ֱ��researchers proposed some explanations as to why some of the patient groups were less likely to receive a prompt referral:

As differences in ethnic minorities were only apparent for older patients, they indicate that communication difficulties may be responsible.
For bladder cancer, women were more than twice as likely as men to have required three or more consultations with their doctor before a decision to refer to hospital was made. In women, there may be difficulties in discriminating symptoms and signs of bladder cancer from those of benign gynaecological conditions or bladder infection.
As young people have a lower rate of cancer, the researchers believe GPs are less likely to consider cancer as a possibility.

̽��ֱ��research used data from more than 41,000 patients with 24 different cancers who took part in the English National Cancer Patient Experience Survey 2010. ( ̽��ֱ��UK government has indicated that patient experience is a critical aspect of measuring care quality.) ̽��ֱ��researchers examined variation in the number of general practitioner consultations with cancer symptoms before hospital referral to diagnose cancer.

“Whilst doctors may have concerns about the accuracy of patient-reported data, we have good reasons to believe the validity of our findings”, said co-author Greg Rubin, Professor of General Practice and Primary Care at Durham ̽��ֱ��. “This is because they correlate well with data collected by general practitioners who took part in the independent National Audit of Diagnosis of Cancer in Primary Care. We hope further strides towards diagnosing cancer earlier will be made through the use of both patient experience and clinical audit data.”

In order to improve the promptness of referrals, the study makes recommendations for both clinicians and policy makers. For clinicians, they highlight the need to be more aware of some of the patient groups and cancers which tended to be diagnosed less promptly and the need to participate in data collection to benchmark their practice. They also suggest that policy makers ‘should explore and evaluate physician-level educational interventions, further development of point-of-care decisions aids, risk calculators and diagnostic tests, and system re-design to enable greater appropriate and timely use of specialist diagnostic tests (such as imaging or endoscopy)’.

Although the researchers are based in the UK, they believe their findings have implications for other countries as well, as they reflect the difficulties of diagnosis cancers with non-specific symptoms and signs more generally. Most patients subsequently diagnosed with cancer first see a doctor in the community regardless of where they live.

Patient information reveals women, young people, ethnic minorities and people with less common cancers have the highest number of pre-referral consultations.

Kokopinto from Flickr

doctor pad

This work is licensed under a Creative Commons Licence. If you use this content on your site please link back to this page.

Yes