Abstract
Cancer of unknown primary (CUP) is a late-stage malignancy with poor prognosis, but we know little about what diagnostic tests and procedures people with CUP receive prior to diagnosis. The purpose of this study was to determine how health service utilisation prior to diagnosis for people with cancer-registry notified CUP differs from those notified with metastatic cancer of known primary. We identified people with a cancer registry notification of CUP (n = 327) from the 45 and Up Study, a prospective cohort of 266,724 people ≥45 years in New South Wales, Australia, matched with up to three controls with a diagnosis of metastatic cancer of known primary (n = 977). Baseline questionnaire data were linked to population health data to identify all health service use, diagnostic tests, and procedures in the month of diagnosis and 3 months prior. We used conditional logistic regression to estimate adjusted odds ratios (ORs) and 95% confidence intervals (CIs). After adjusting for age and educational attainment, people with a cancer-registry notified CUP diagnosis were more likely to be an aged care resident (OR = 2.78, 95%CI 1.37-5.63), have an emergency department visit (OR = 1.65, 95%CI 1.23-2.21), serum tumor marker tests (OR = 1.51, 95%CI 1.12-2.04), or a cytology test without immunohistochemistry (OR = 2.01, 95%CI 1.47-2.76), and less likely to have a histopathology test without immunohistochemistry (OR = 0.43, 95%CI 0.31-0.59). Neither general practitioner, specialist, allied health practitioner or nurse consultations, hospitalisations, nor imaging procedures were associated with a CUP diagnosis. The health service and diagnostic pathway to diagnosis differs markedly for people notified with CUP compared to those with metastatic cancer of known primary. While these differences may indicate missed opportunities for earlier detection and appropriate management, for some patients they may be clinically appropriate.
Highlights
Cancer of unknown primary site (CUP) is the 14th most commonly diagnosed cancer and the 6th most common cause of cancer death in Australia.[1]
Specialist, allied health practitioner or nurse consultations, hospitalisations, nor imaging procedures were associated with a CUP diagnosis
The health service and diagnostic pathway to diagnosis differs markedly for people notified with CUP compared to those with metastatic cancer of known primary
Summary
Cancer of unknown primary site (CUP) is the 14th most commonly diagnosed cancer and the 6th most common cause of cancer death in Australia.[1]. Studies of how people diagnosed with CUP interact with the health system prior to their definitive diagnosis, and what investigations they receive, are limited.[8,12] there are no Australian CUP clinical practice guidelines, the US National Comprehensive Cancer Network (NCCN) and the European Society for Medical Oncology (ESMO) CUP-specific guidelines support the judicious use of diagnostic investigations, in keeping with a patient’s prognosis and treatment options.[13,14] Yet, the diagnostic pathway of patients with a cancer-registry notified CUP diagnosis is highly variable,[8,15,16] which may reflect heterogeneity in clinical presentation and patient characteristics. The purpose of this study was to determine how health service utilisation prior to diagnosis for people with cancer-registry notified CUP differs from those notified with metastatic cancer of known primary.
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