Date Of First Presentation Research Articles

Predictors of time to diagnosis and treatment: A retrospective cohort study of patients with clinically localized prostate cancer in Nigeria.

e23123 Background: Equitable access to the management of early-stage prostate cancer is important for optimal outcome in the diagnostic and curative treatment pathway of patients. This study aimed to identify the predictors of time to treatment and time to diagnosis in these patients. Methods: This was a cohort study of 110 patients with clinically localized prostate cancer (T1-T3a, N0, M0) in three government-funded tertiary hospitals in Nigeria. Retrospective data on sociodemographic status, co-morbid conditions, clinical, pathological and radiological quality metrics, date of first presentation for cancer-related complaint in the tertiary hospital, date of diagnosis of prostate cancer, and the date of commencement of first cancer-directed treatment were collected. Primary endpoint was the time from diagnosis to treatment and the secondary endpoint was the time from presentation to diagnosis. Predictors were determined by Cox proportional hazards using Stata software, version 18.0 with a p-value of less than 0.05 considered significant. Results: Twelve percent (n = 13) of the patients had a family history of prostate cancer. Fifty-four percent (n = 59) had other co-morbid conditions. Nearly one-third, 29% (n = 32) had retired from their primary occupation and 10% (n = 11) were covered by health insurance. The overall median time to diagnosis was 30 (interquartile range (IQR) 10 - 48) days. The median time to treatment commencement was 32 (IQR 19 - 82) days for ADT; 57 (IQR 50 - 63) days for active surveillance; 45 (IQR 21 - 78) days for radical radiotherapy; and 100 (IQR 0 - 127) days for radical prostatectomy. Diagnostic PSA documentation independently predicted delayed time to diagnosis (adjusted HR = 0.22 with 95% CI [0.05,0.97]) while those with guideline concordant imaging investigations independently predicted longer time to treatment (adjusted HR = 0.63 with 95% CI [0.40,0.99]). Conclusions: The documentation of PSA level and use of guideline concordant imaging investigations were significantly associated with delayed time to care. Studies on interventions to reduce barriers associated with these factors is warranted to strengthen equitable access to care in this setting.

Analysis of Time to Treatment and Survival Among Adults Younger Than 50 Years of Age With Colorectal Cancer in Canada

Colorectal cancer (CRC) is uncommon in adults younger than 50 years of age, so this population may experience delays to treatment that contribute to advanced stage and poor survival. To investigate whether there is an association between time from presentation to treatment and survival in younger adults with CRC. This retrospective cohort study used linked population-based data in Ontario, Canada. Participants included patients with CRC aged younger than 50 years who were diagnosed in Ontario between 2007 and 2018. Analysis was performed between December 2019 and December 2022. Administrative and billing codes were used to identify the number of days between the date of first presentation and treatment initiation (overall interval). The associations between increasing overall interval, overall survival (OS), and cause-specific survival (CSS) were explored with restricted cubic spline regression. Multivariable Cox proportional hazards models were also fit for OS and CSS, adjusted for confounders. Analyses were repeated in a subset of patients with lower urgency, defined as those who did not present emergently, did not have metastatic disease, did not have cross-sectional imaging or endoscopy within 14 days of first presentation, and had an overall interval of at least 28 days duration. Among 5026 patients included, the median (IQR) age was 44.0 years (40.0-47.0 years); 2412 (48.0%) were female; 1266 (25.2%) had metastatic disease and 1570 (31.2%) had rectal cancer. The lower-urgency subset consisted of 2548 patients. The median (IQR) overall interval was 108 days (55-214 days) (15.4 weeks [7.9-30.6 weeks]). Patients with metastatic CRC had shorter median (IQR) overall intervals (83 days [39-183 days]) compared with those with less advanced disease. Five-year overall survival was 69.8% (95% CI, 68.4%-71.1%). Spline regression showed younger patients with shorter overall intervals (<108 days) had worse OS and CSS with no significant adverse outcomes of longer overall intervals. In adjusted Cox models, overall intervals longer than 18 weeks were not associated with significantly worse OS or CSS compared with those waiting 12 to 18 weeks (OS: HR, 0.83 [95% CI, 0.67-1.03]; CSS: HR, 0.90 [95% CI, 0.69-1.18]). Results were similar in the subset of lower-urgency patients, and when stratified by stage. In this cohort study of 5026 patients with CRC aged younger than 50 years of age in Ontario, time from presentation to treatment was not associated with advanced disease or poor survival. These results suggest that targeting postpresentation intervals may not translate to improved outcomes on a population level.

Evaluation of a multifaceted medication review in older patients in the outpatient setting: a before-and-after study

Background The prevalence of medication-related emergency department visits and acute hospital admissions in older patients is rising due to the ageing of the population and increasing prevalence of multimorbidity and associated polypharmacy.Aim To explore whether a combined medication review performed in the outpatient setting reduces the number of medication-related emergency department visits and hospital (re)admissions.Method All consecutive patients visiting the geriatric outpatient clinic underwent a multifaceted medication review (i.e. evaluation by at least a geriatrician, and/or pharmacist and use of clinical decision support system). Subsequently, we analysed the number of, and reason for, emergency department visits, acute hospital admissions and readmissions in the year prior to and the year following the index-date (date of first presentation and medication review).Results A multifaceted medication review reduced the number of potentially medication-related emergency department visits (38.9% vs. 19.6%, p < 0.01), although the total number of ED visits or acute hospital admissions per patient in the year before and after medication review did not differ.Conclusion A multifaceted medication review performed in the outpatient clinic reduced the number of potentially medication-related emergency department visits and could therefore reduce negative health outcomes and healthcare costs.

HPB P02 Audit of Delays in the Definitive Management of Suspected Pancreatic Malignancies

Abstract Background Approximately 10,500 people in the UK are diagnosed with pancreatic cancer each year. (1) Patients can present to their GP, to A&amp;E, or can be referred following an incidental finding on a pathology review. Decisions within the South-West of England regarding patient's most appropriate treatment pathways are made during Specialist Multi-Disciplinary Team (SMDT) meetings hosted by University Hospitals Plymouth (UHP). Treatment options can include surgery, chemotherapy or a palliative approach. (2) The NHS standard for patients to have their first definitive treatment following an urgent GP referral is a maximum of 62 days. (3) Shorter waiting times have been shown to correlate to an improved patient experience, and may result in earlier diagnoses, treatment, fewer complications, and overall improved cancer outcomes. (4) This audit aims to review the current practice of the time taken between the date of referral and the first definitive treatment of pancreatic malignancies discussed within the SMDT over a two-year period. Currently, there are no studies examining the relationship between delays and patient outcomes with pancreatic malignancies in England. (5) Our evaluation will also examine this and enable future planning into research studies with a particular focus on reducing delays in treatment. Methods A retrospective, cohort study across the South-West of England analysing the delays in the definitive management of suspected pancreatic malignancies within a two-year period of weekly SMDT discussions. The inclusion criteria consists of patients referred locally from Plymouth Hospitals NHS Trust with pancreatic and peri-ampullary malignancies, discussed between 01/01/19 and 31/12/20. A total of 94 patients were discussed within the SMDT with suspected pancreatic and peri-ampullary cancers in 2019. 61 of these patients were referred locally from Plymouth Hospitals NHS Trust and will be the focus for this abstract. Following approval from the hospitals ethics board, data has been retrospectively collected by our team of four medical students into the online RedCap database. (6) Data has been collected from following hospital systems: Somerset Cancer Register, Clinical Record Interactive System, e-discharge and patient care manager and the main hospital electronic system. Data collection points include patient age, date of initial presentation, dates and types of investigations, date of SMDT referral, number and outcome of SMDT discussions, date of treatment commencement, and date of death if applicable. The data has been anonymised to explore the sources of delay from the date of referral until definitive treatment in patients with pancreatic malignancies. Results The age range for our preliminary data is 50–91. The median age is 71. Preliminary data shows that overall: For patients surgically managed, it took a median of 0 days from their first presentation until their date of surgery (range 189), with longer delays for those referred form their GP compared to those referred via admission. For patients managed with chemotherapy, it took a median of 81 days from their date of first presentation until their date of first chemotherapy treatment (range 231).For patients treated palliatively, it took a median of 23 days from their date of first presentation to the date of decision for palliative treatment (range 77). The number of SMDT discussions per patient had a range of 7, with a median of 2. On further analysis, delays lie between: The date of first presentation to SMDT referral, especially if referred via GP (median 9, range 17) compared to via admission (median 0, range 72) The date of SMDT referral and date of first discussion (median 9, range 53) The date of first SMDT discussion and date of first biopsy (median 31, range 165) Conclusions Preliminary data analysis shows that patients are waiting longer than nationally stipulated NHS guidelines. Upon complete data analysis of all patients first discussed within the SMDT in 2019 and 2020, an evaluation of the timeframe and delays to receiving definite management will highlight the adherence to the NHS 62-day target and whether this has improved over time. We will consider the impact of recurring SMDT discussions on patient outcomes. We will identify any trends between the time taken from being first seen until definitive treatment and analyse the impact of these on the mortality of our patient cohort. Could this be contributing to the poor survival of pancreatic malignancies in England compared to the rest of Europe? (7) On completion, analysis will enable identification of the factors contributing to any delays in the existing treatment pathway in the South-West of the England. We will suggest future means of addressing these to improve this timeframe in accordance with NHS targets, with the goal to potentially improve patient outcomes.

Agreement between questionnaires and registry data on routes to diagnosis and milestone dates of the cancer diagnostic pathway

BackgroundThe routes to diagnosis and the time intervals along the diagnostic pathway affect cancer outcomes. Some data on routes to diagnosis and milestone dates can be extracted from registries or databases. When this data is incomplete, inaccurate or non-existing, other data sources are needed. This study investigates the agreement between multiple data sources on routes to diagnosis and milestone dates of cancer pathway. MethodsInformation on routes to diagnosis and milestone dates were compared across four data sources (cancer patients, general practitioners, cancer specialists and registries) for breast, colorectal, lung and ovarian cancers across the UK, Scandinavia, Canada and Australia. Agreement on routes to diagnosis and milestone dates was assessed by Kappa and AC1 coefficients and Lin’s concordance correlation coefficient (CCC). Results4502 patients were included in the analysis of routes to diagnosis. The agreement was almost perfect (kappa = 0.15–0.88, AC1 = 0.86–0.91) for breast cancer, substantial to almost perfect (kappa = 0.07–0.86, AC1 = 0.74–0.93) for colorectal and ovarian cancers, and substantial (kappa = 0.09–0.11, AC1 = 0.65–0.74) for lung cancer. 2287 patients were included in the analysis of milestone dates. The agreement was adequate for all cancer types (CCC = 0.88–0.99); highest agreement was seen for date of diagnosis (CCC = 0.94–0.99). ConclusionWe found a reasonable agreement between patient/physician questionnaires and registry data for routes to diagnosis and milestone dates. The agreement on routes to diagnosis was generally higher for breast cancer than for colorectal, ovarian and lung cancers. Lower agreement was seen on date of first presentation to primary care and date of treatment initiation compared to date of diagnosis.

The iHOPE-20 study: mortality in first episode psychosis-a 20-year follow-up of the Dublin first episode cohort.

Increased mortality rates have been found in those with a diagnosis of psychosis; studies suggest a shortened life expectancy of up to 20years less than that of the general population. This study aimed to investigate the mortality of a first episode psychosis cohort at 20-year follow-up, compare it to that of the general Irish population, and explore whether the mortality gap has changed over time. 171 individuals diagnosed with a first episode psychosis identified between 1995 and 1999 in a community mental health service were traced. Mortality was established by matching death certificates to deceased cohort members (using name, age at date of death, and address at date of death). Date of first presentation to service was used as date of entry point and date of death or end of follow-up as the end point. Of the 171 cases there were 20 deaths during follow-up. Nine deaths were attributed to natural causes; 7 to unnatural causes; and 4 were unknown. Comparing standardised mortality rates at 20-year follow-up to those at 12year showed a reduction in rates over time. Findings suggest that the mortality gap in people with schizophrenia and other psychoses remains high, especially in young males.

Distribution and Impact of Comorbidities on Survival and Leukemic Transformation in Myeloproliferative Neoplasm (MPN)-Associated Myelofibrosis (MF)

Introduction. Myelofibrosis is a disease characterized by aberrant bone marrow function with eventual fibrosis. Current widely-used disease prognostic indices, such as the Dynamic International Prognostic Scoring System (DIPSS) do not take into account comorbidities, which may have significant effects on patient survival as well as disease course. We sought to describe the comorbidity distribution in this patient population and assess the impact of comorbidities as scored by two different widely used scales in clinical practice, the Adult Comorbidity Evaluation 27 (ACE-27) and the Hematopoietic Cell Transplant Comorbidity Index (HCT-CI), on overall survival and leukemic transformation in myelofibrosis. A score of 3 on ACE-27 or ≥3 on HCT-CI generally indicates a high burden (severe) comorbidities.Methods. We conducted a retrospective study of 309 patients seen at the MPN program at the Princess Margaret Cancer Centre, with a confirmed diagnosis of myelofibrosis [primary myelofibrosis (PMF), post-essential thrombocytopenia (PET-MF) or post-polycythemia vera (PPV-MF)]. Patients were seen from 1999-2014 with a median follow-up time of 2 years. Time to death and leukemic transformation was examined from the date of first presentation to our centre. Our primary aim was to examine the impact of comorbidity scores, as assessed by ACE-27 and the HCT-CI, on overall survival. In a secondary analysis we examined the impact of comorbidity scores on leukemic transformation. Multivariable Cox proportional hazards models were constructed for the primary and secondary outcomes. A series of descriptive analyses were carried out examining the distribution of various comorbidities as captured by the two scales.Results. The most common comorbidities captured by ACE-27 were hypertension (n=92, 22.3%), diabetes mellitus (n=43, 10.4%), venous disease (n=26, 6.3%), solid tumour including melanoma (n=26, 6.3%), and angina/coronary artery disease (n=23, 5.6%). The most common comorbidities captured by HCT-CI were cardiac (n=49, 17.3%), diabetes (n=43, 15.2%), mild hepatic (n=28, 9.9%), cerebrovascular disease (n=25, 8.8%), prior solid tumour (n=24, 8.5%). The distribution of comorbidity scores as compared between scales is shown in Table 1.A total of 78 patients (25.2%) experienced the primary outcome of interest, which was all-cause death. For the primary outcome of overall survival, there were differences across groups of patients with different comorbidity scores using ACE-27 or HCT-CI, with the highest severity groups having worse outcomes (Figure 1). Progressively increasing DIPSS categories (Low, Intermediate-1, Intermediate-2, and High risk) were also associated with worse overall survival. On multivariable survival analysis, an ACE-27 score of 3 when compared to a lower score of 0-1 was associated with an almost two-fold increase in the risk of all-cause death [HR 1.95 (95% CI 1.06-3.58), p=0.03]. On multivariable analysis, an HCT-CI score of 3+ when compared with 0-1 was marginally significantly associated with an increased risk of all-cause death [HR 1.60 (95% CI 0.96-2.68), p=0.07]. Interaction terms were tested between the scores and age at presentation and no effect of age on survival across varying severities of comorbidities was found. In our secondary analysis, there was no impact of the ACE-27 or HCT-CI on leukemic transformation.Conclusions. ACE-27 picked up severe co-morbidities in 13% of patients in our cohort while HCT-CI picked up severe comorbidities in 23%. Although the incidence of severe co-morbidities was lower when assessed by ACE-27, the overall impact on survival of severe comorbidities as assessed by both scores is likely to be similar. The presence of severe comorbidities at the time of diagnosis conferred a significant survival disadvantage in patients with myelofibrosis, but had no impact on progression to leukemic transformation. [Display omitted] [Display omitted] DisclosuresPanzarella:Cellgene: Consultancy. Schimmer:Novartis: Honoraria. Schuh:Amgen: Membership on an entity's Board of Directors or advisory committees. Yee:Novartis Canada: Membership on an entity's Board of Directors or advisory committees, Research Funding. Gupta:Novartis: Consultancy, Honoraria, Research Funding; Incyte: Consultancy, Research Funding.

Time from first presentation in primary care to treatment of symptomatic colorectal cancer: effect on disease stage and survival.

Background:British 5-year survival from colorectal cancer (CRC) is below the European average, but the reasons are unclear. This study explored if longer provider delays (time from presentation to treatment) were associated with more advanced stage disease at diagnosis and poorer survival.Methods:Data on 958 people with CRC were linked with the Scottish Cancer Registry, the Scottish Death Registry and the acute hospital discharge (SMR01) dataset. Time from first presentation in primary care to first treatment, disease stage at diagnosis and survival time from date of first presentation in primary care were determined. Logistic regression and Cox survival analyses, both with a restricted cubic spline, were used to model stage and survival, respectively, following sequential adjustment of patient and tumour factors.Results:On univariate analysis, those with <4 weeks from first presentation in primary care to treatment had more advanced disease at diagnosis and the poorest prognosis. Treatment delays between 4 and 34 weeks were associated with earlier stage (with the lowest odds ratio occurring at 20 weeks) and better survival (with the lowest hazard ratio occurring at 16 weeks). Provider delays beyond 34 weeks were associated with more advanced disease at diagnosis, but not increased mortality. Following adjustment for patient, tumour factors, emergency admissions and symptoms and signs, no significant relationship between provider delay and stage at diagnosis or survival from CRC was found.Conclusions:Although allowing for a nonlinear relationship and important confounders, moderately long provider delays did not impact adversely on cancer outcomes. Delays are undesirable because they cause anxiety; this may be fuelled by government targets and health campaigns stressing the importance of very prompt cancer diagnosis. Our findings should reassure patients. They suggest that a health service's primary emphasis should be on quality and outcomes rather than on time to treatment.

Agreement between patient-reported and doctor-reported patient intervals and date of first symptom presentation in cancer diagnosis – A population-based questionnaire study

Background: The concept of delay in cancer diagnosis has been a scientific issue for decades, and there is still no standardised and validated way to measure the time intervals. One of the intervals that are difficult to measure is the patient interval (i.e. the period from the patient's first symptom until the first presentation to the health care system) because dates of symptom onset and first presentation are difficult to establish precisely. Further, since patients may have another experience of the diagnostic pathway than e.g. the general practitioner (GP), a reasonable question remains whether patients and GPs agree on these important milestones. The objective of this study was to analyse the agreement between patient-reported and GP-reported patient intervals and date of first presentation of cancer-related symptom(s) to the GP. Methods: On the basis of a cohort study, we included incident cancer patients from the former Aarhus County from 1 September, 2004 to 31 August, 2005. Both patients and GPs reported the length of the patient interval and the date of the first presentation to the GP with a cancer-related symptom measured by self-administered questionnaires. Agreement was measured using agreement-survival plots and Lin's concordance correlation coefficient (CCC). Results: There was full agreement between GP- and patient-reported patient intervals in 21.0% of all the cancer cases. In 50.1% of cases, patients and GPs agreed about the patient interval within a margin of one month. There was full agreement between GP- and patient-reported date of first presentation in 37.5% of the cancer cases and within one week in 52.0% of all the cancer cases. Overall, the agreement on the length of the patient interval was poor (CCC=0.513), but better for patients presenting with alarm symptoms. The agreement was moderate between GP- and patient-reported dates of first presentation (CCC=0.924). Conclusion: We found that GPs systematically reported a longer patient interval than patients did. We found moderate agreement on reported date of first presentation of symptoms to the GP, meaning that the disagreement in reported patient interval is related to date of first symptom rather than date of first presentation to the GP.

Diagnostic interval and mortality in colorectal cancer: U-shaped association demonstrated for three different datasets

ObjectiveTo test the theory of a U-shaped association between time from the first presentation of symptoms in primary care to the diagnosis (the diagnostic interval) and mortality after diagnosis of colorectal cancer (CRC). Study Design and SettingThree population-based studies in Denmark and the United Kingdom using data from general practitioner’s questionnaires, interviewer-administered patient questionnaires, and primary care records, respectively. ResultsDespite variations in the potential selection and information bias when using different methods of identifying the date of first presentation, the association between the length of the diagnostic interval and 5-year mortality rate after the diagnosis of CRC was the same for all three types of data: displaying a U-shaped association with decreasing and subsequently increasing mortality with longer diagnostic intervals. ConclusionUnknown confounding and in particular confounding by indication is likely to explain the counterintuitive findings of higher mortality among patients with very short diagnostic intervals, but cannot explain the increasing mortality with longer diagnostic intervals. The results support the theory that longer diagnostic intervals cause higher mortality in patients with CRC.

The influence of vascular risk factors on the survival rate of patients with dementia with Lewy bodies and Alzheimer disease

Background and purposeThe aim of this study was to determine whether dementia with Lewy bodies (DLB) progresses more rapidly than Alzheimer disease (AD) and to compare survival after dementia onset and mortality in both dementia groups. Material and methodsA medical records analysis of AD (n = 183) and DLB (n = 51) patients was performed to determine age at onset of symptoms, the date of first presentation to the psychiatric services, dementia severity at diagnosis (MMSE score), and mean disease duration before diagnosis. Categorical data regarding vascular risk factors were collected. Projected decline rate (MMSE/year), survival rate after the diagnosis of dementia, mean survival time after diagnosis and mortality rate were calculated and compared between DLB and AD groups. ResultsThe comparison of clinical and demographic parameters revealed no significant differences between groups, apart from a more pronounced decline rate in the DLB group. Diabetes, and to a lesser extent hypertension, influenced survival in AD, but not in DLB subjects. Overall, however, the difference in mortality rates and survival time between DLB and AD subjects cannot be attributed to the presence of any vascular risk factor analysed. DLB, independently of the presence of vascular risk factors, seems to be a more aggressive disorder than AD, when mortality and survival time are taken into account. ConclusionsMore rapid progression of cognitive decline and shorter duration of dementia were found in DLB in this naturalistic study. The findings may have important implications for the management and treatment of DLB and should be confirmed in prospective studies.

Three years survival in patients with a clinical diagnosis of dementia with Lewy bodies.

The majority of information available on the prognosis of dementia with Lewy bodies (DLB) is based on retrospective data from autopsy series, which are subject to selection bias due to the specific reasons patients are referred for post-mortem studies. The earlier studies comparing DLB patients with patients with Alzheimer's disease (AD) suggest that the mean duration of illness is shorter in DLB patients than in patients with AD. However, more recent studies have not observed significant differences between DLB and AD in age of onset, age at death or duration of illness. We report a 3 year follow-up of a cohort of 114 consecutive patients with dementia, referred to an old age psychiatric service and diagnosed using ICD 10 criteria and the McKeith and Byrne DLB criteria. The case notes of all patients were reviewed to determine the date of onset of symptoms and the date of first presentation to the psychiatric services. Information about outcome was gathered from case notes, hospital files and general practitioner (GP) records. Of the original sample of 114 patients, 106 could be traced. Sixty-four had died and 42 were still alive at the time of the follow-up. Thirty-two patients had originally been assigned the diagnosis of DLB, 43 the diagnosis of AD, 31 vascular dementia and other diagnoses. There were no differences between the AD and DLB group in age at onset, age at death or survival. We have not found any evidence that the prognosis of clinically diagnosed DLB patients is worse than that of patients with a clinical diagnosis of AD.