Abstract
BackgroundCancer Patient Pathways (CPPs) were introduced in 2000–2015 in several European countries, including Denmark, to reduce the time to diagnosis and treatment initiation and ultimately improve patient survival. Yet, the prognostic consequences of implementing CPPs remain unknown for symptomatic cancer patients diagnosed through primary care.We aimed to compare survival and mortality among symptomatic patients diagnosed through a primary care route before, during and after the CPP implementation in Denmark.MethodsBased on data from the Danish Cancer in Primary Care (CaP) Cohort, we compared one- and three-year standardised relative survival (RS) and excess hazard ratios (EHRs) before, during and after CPP implementation for seven types of cancer and all combined (n = 7725) by using life-table estimation and Poisson regression. RS estimates were standardised according to the International Cancer Survival Standard (ICSS) weights. In addition, we compared RS and EHRs for CPP and non-CPP referred patients to consider potential issues of confounding by indication.ResultsIn total, 7725 cases were analysed: 1202 before, 4187 during and 2336 after CPP implementation. For all cancers combined, the RS3years rose from 45% (95% confidence interval (CI): 42;47) before to 54% (95% CI: 52;56) after CPP implementation. The excess mortality was higher before than after CPP implementation (EHR3years before vs. after CPP = 1.35 (95% CI: 1.21;1.51)). When comparing CPP against non-CPP referred patients, we found no statistically significant differences in RS, but we found lower excess mortality among the CPP referred (EHR1year CPP vs. non-CPP = 0.86 (95% CI: 0.73;1.01)).ConclusionWe found higher relative survival and lower mortality among symptomatic cancer patients diagnosed through primary care after the implementation of CPPs in Denmark. The observed changes in cancer prognosis could be the intended consequences of finding and treating cancer at an early stage, but they may also reflect lead-time bias and selection bias. The finding of a lower excess mortality among CPP referred compared to non-CPP referred patients indicates that CPPs may have improved the cancer prognosis independently.
Highlights
Cancer Patient Pathways (CPPs) were introduced in 2000–2015 in several European countries, including Denmark, to reduce the time to diagnosis and treatment initiation and improve patient survival
Survival and excess mortality across the time of CPP implementation Patients diagnosed after CPP implementation had higher one- and three-year relative survival (RS1year and RS3year) than patients diagnosed before CPP implementation for each of the seven types of cancer, with statistically significant differences for lung cancer, gynaecological cancers and all cancers combined (Tables 2 and 3)
The excess mortality ratios at one- and three-year follow-up (EHR1year & EHR3year) were higher before than after CPP implementation for all cancer types (EHR1year = 1.25 & EHR3years = 1.35), with statistically significant differences for lung cancer, gynaecological cancers and all cancers combined (Tables 4 and 5)
Summary
Cancer Patient Pathways (CPPs) were introduced in 2000–2015 in several European countries, including Denmark, to reduce the time to diagnosis and treatment initiation and improve patient survival. The prognostic consequences of implementing CPPs remain unknown for symptomatic cancer patients diagnosed through primary care. We aimed to compare survival and mortality among symptomatic patients diagnosed through a primary care route before, during and after the CPP implementation in Denmark. Many countries with gatekeeper systems have sought to increase the survival by implementing comprehensive national cancer guidelines, such as the English NICE Guidance, the Scottish SIGN Guidelines and the Danish Cancer Patient Pathways (CPPs) [7,8,9,10,11,12,13,14,15]. The prognostic benefits from implementing CPPs remain unknown for symptomatic cancer patients diagnosed through primary care, this group constitutes more than 75% of all cancer patients [16, 17]. The few existing studies are too small and underpowered to detect changes in survival [18,19,20], or they fail to recognise important issues of selection and confounding by indication related to the radical changes in referral routes [21,22,23,24,25,26]
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