National Cancer Diagnosis Audit Research Articles

Revisiting Cancer Diagnosis in Scotland: Further Insights from the Second Scottish National Cancer Diagnosis Audit

Objective. To characterise cancer diagnosis in Scottish primary care in 2018/19 and draw comparisons with diagnostic activity in 2014. Methods. A national audit of cancer diagnosis undertaken in Scottish general practices. Participating GPs collected diagnostic pathway data on patients diagnosed with cancer in 2018/19 from medical records. These data were supplemented by linkage to the Scottish Cancer Registry and previous audit data from 2014. Analyses explored and compared patient demographics, presentation, diagnostic routes, and intervals. Results. Seventy-three practices submitted data on 2,014 cases in 2014 and 90 practices submitted data on 2,318 cases in 2018/2019. Individual demographics and types of cancer were similar. There was a higher proportion of USC (urgent suspected cancer) referrals in 2019 than 2014 (42.9% vs 38.1%, p=0.008) but a similar proportion of emergency presentations (19.2% vs 20.4%). Primary care (median 4 (IQR 0–22) vs 5 (0–23)) and diagnostic intervals (27 (10–59) vs 30 (13–68)) were similar in both periods. Significantly fewer (24.5% vs 28.3, p=0.015) had a diagnostic interval >60 days in 2019 than 2014. Harder to diagnose cancers were more likely to present as emergencies and be subject to prolonged delays in both cohorts. Conclusions. The 2014 and 2018/19 cohorts were broadly similar. There is limited evidence that USC use had increased between 2014 and 2018/19. Harder to diagnose cancers are still most likely to present as emergencies and be subject to delays. Overall, it seems there were small improvements in cancer diagnosis prepandemic and a further audit could examine evidence for a postpandemic recovery.

The presenting symptom signatures of incident cancer: evidence from the English 2018 National Cancer Diagnosis Audit

BackgroundUnderstanding relationships between presenting symptoms and subsequently diagnosed cancers can inform symptom awareness campaigns and investigation strategies.MethodsWe used English National Cancer Diagnosis Audit 2018 data for 55,122 newly diagnosed patients, and examined the relative frequency of presenting symptoms by cancer site, and of cancer sites by presenting symptom.ResultsAmong 38 cancer sites (16 cancer groups), three classes were apparent: cancers with a dominant single presenting symptom (e.g. melanoma); cancers with diverse presenting symptoms (e.g. pancreatic); and cancers that are often asymptomatically detected (e.g. chronic lymphocytic leukaemia). Among 83 symptoms (13 symptom groups), two classes were apparent: symptoms chiefly relating to cancers of the same body system (e.g. certain respiratory symptoms mostly relating to respiratory cancers); and symptoms with a diverse cancer site case-mix (e.g. fatigue). The cancer site case-mix of certain symptoms varied by sex.ConclusionWe detailed associations between presenting symptoms and cancer sites in a large, representative population-based sample of cancer patients. The findings can guide choice of symptoms for inclusion in awareness campaigns, and diagnostic investigation strategies post-presentation when cancer is suspected. They can inform the updating of clinical practice recommendations for specialist referral encompassing a broader range of cancer sites per symptom.

The impact of rurality on patient experience and diagnostic pathway intervals in Scotland’s cancer patients: Further results from a national cancer diagnosis audit

BackgroundIn Scotland 17 % of the population reside rurally and previous research has demonstrated worse cancer outcomes in this group. The underlying reason for this is unclear. This study aims to determine whether patient presenting factors, GP consultation factors or the diagnostic pathways differ between urban and rural patients within Scotland. MethodsThis study combined two Scottish National Cancer Diagnosis Audits. Participating GPs collected data on the diagnostic pathway from primary to secondary care for cancer patients diagnosed during the audit period. Using the Scottish Government Urban Rural Classification, patients were designated as rural or urban dwellers and compared in descriptive analyses. Key cancer intervals (primary, diagnostic, secondary and treatment interval) were compared between urban and rural dwellers with an additional adjusted analysis for the main cancer sites. ResultsA total of 4309 cancer diagnoses were included in the study; 22 % were in patients from rural locations. Rural patients had significantly more consultations and investigations prior to referral than their urban counterparts. There was no difference in prolonged cancer pathways between the two groups except in lung cancer patients where rural patients had a significantly increased odds of a diagnostic interval of >90 days. ConclusionOur findings suggest differences in the interaction between patients and GPs prior to referral in urban and rural settings. However, this does not appear to lead to prolonged patient pathways, except in lung cancer. Further research is needed to determine whether this delay is clinically significant and contributing to poorer outcomes in Scottish rural dwellers with lung cancer.

Pre-Referral Primary Care Blood Tests and Symptom Presentation before Cancer Diagnosis: National Cancer Diagnosis Audit Data.

Blood tests can support the diagnostic process in primary care. Understanding how symptomatic presentations are associated with blood test use in patients subsequently diagnosed with cancer can help to benchmark current practices and guide interventions. English National Cancer Diagnosis Audit data on 39,751 patients with incident cancer in 2018 were analysed. The frequency of four generic (full blood count, urea and electrolytes, liver function tests, and inflammatory markers) and five organ-specific (cancer biomarkers (PSA or CA125), serum protein electrophoresis, ferritin, bone profile, and amylase) blood tests was described for a total of 83 presenting symptoms. The adjusted analysis explored variation in blood test use by the symptom-positive predictive value (PPV) group. There was a large variation in generic blood test use by presenting symptoms, being higher in patients subsequently diagnosed with cancer who presented with nonspecific symptoms (e.g., fatigue 81% or loss of appetite 79%), and lower in those who presented with alarm symptoms (e.g., breast lump 3% or skin lesion 1%). Serum protein electrophoresis (reflecting suspicion of multiple myeloma) was most frequently used in cancer patients who presented with back pain (18%), and amylase measurement (reflecting suspicion of pancreatic cancer) was used in those who presented with upper abdominal pain (14%). Prostate-specific antigen (PSA) use was greatest in men with cancer who presented with lower urinary tract symptoms (88%), and CA125 in women with cancer who presented with abdominal distention (53%). Symptoms with PPV values between 2.00-2.99% were associated with greater test use (64%) compared with 52% and 51% in symptoms with PPVs in the 0.01-0.99 or 1.00-1.99% range and compared with 42% and 31% in symptoms with PPVs in either the 3.00-4.99 or ≥5% range (p < 0.001). Generic blood test use reflects the PPV of presenting symptoms, and the use of organ-specific tests is greater in patients with symptomatic presentations with known associations with certain cancer sites. There are opportunities for greater blood test use in patients presenting with symptoms that do not meet referral thresholds (i.e., <3% PPV for cancer) where information gain to support referral decisions is likely greatest. The findings benchmark blood test use in cancer patients, highlighting opportunities for increasing use.

Primary care blood tests before cancer diagnosis: National Cancer Diagnosis Audit data.

Blood tests can support the diagnostic process in patients with cancer but how often they are used is unclear. To explore use of common blood tests before cancer diagnosis in primary care. English National Cancer Diagnosis Audit data on 39 752 patients with cancer diagnosed in 2018. Common blood test use (full blood count [FBC], urea and electrolytes [U&E], and liver function tests [LFTs]), variation by patient and symptom group, and associations with the primary care interval and the diagnostic interval were assessed. At least one common blood test was used in 41% (n = 16 427/39 752) of patients subsequently diagnosed with cancer. Among tested patients, (n = 16 427), FBC was used in 95% (n = 15 540), U&E in 89% (n = 14 555), and LFTs in 76% (n = 12 414). Blood testing was less common in females (adjusted odds ratio versus males: 0.92, 95% confidence interval [CI] = 0.87 to 0.98) and Black and minority ethnic patients (0.89, 95% CI = 0.82 to 0.97 versus White), and more common in older patients (1.12, 95% CI = 1.06 to 1.18 for ≥70 years versus 50-69 years). Test use varied greatly by cancer site (melanoma 2% [ n = 55/2297]; leukaemia 84% [ n = 552/661]). Fewer patients presenting with alarm symptoms alone were tested (24% [ n = 3341/13 778]) than those with non-alarm symptoms alone (50% [ n = 8223/16 487]). Median primary care interval and diagnostic interval were longer in tested than non-tested patients (primary care interval: 10 versus 0 days; diagnostic interval: 49 versus 32 days, respectively, P<0.001 for both), including among tested patients with alarm symptoms (primary care interval: 4 versus 0 days; diagnostic interval: 41 versus 22 days). Two-fifths of patients subsequently diagnosed with cancer have primary care blood tests as part of their diagnostic process. Given variable test use, research is needed on the clinical context in which blood tests are ordered.

Morbidity and measures of the diagnostic process in primary care for patients subsequently diagnosed with cancer.

BackgroundThere is uncertainty regarding how pre-existing conditions (morbidities) may influence the primary care investigation and management of individuals subsequently diagnosed with cancer.MethodsWe identified morbidities using information from both primary and secondary care records among 11,716 patients included in the English National Cancer Diagnosis Audit (NCDA) 2014. We examined variation in 5 measures of the diagnostic process (the primary care interval, diagnostic interval, number of pre-referral consultations, use of primary care-led investigations, and referral type) by both primary care- and hospital records-derived measures of morbidity.ResultsMorbidity prevalence recorded before cancer diagnosis was almost threefold greater using the primary care (75%) vs secondary care-derived measure (28%). After adjustment, there was limited variation in the primary care interval and the number of pre-referral consultations by either definition of morbidity. Patients with more severe morbidities were less likely to have had a primary care-led investigation before cancer diagnosis compared with those without any morbidity (adjusted odds ratio, OR [95% confidence interval]: 0.72 [0.60–0.86] for Charlson score 3+ vs 0; joint P < 0.001). Patients with multiple primary care-recorded conditions or a Charlson score of 3+ were more likely to have diagnostic intervals exceeding 60 days (aOR: 1.26 [1.10–1.45] and 1.19 [>1.00–1.41], respectively), and more likely to receive an emergency referral (aOR: 1.60 [1.26–2.02] and 1.61 [1.26–2.06], respectively).ConclusionAmong cancer cases with up to 2 morbidities, there was no evidence of differences in diagnostic processes and intervals in primary care but higher morbidity burden was associated with longer time to diagnosis and higher likelihood of emergency referral.

The prevalence of chronic conditions in patients diagnosed with one of 29 common and rarer cancers: A cross-sectional study using primary care data

BackgroundPre-existing chronic conditions (morbidities) influence the diagnosis and management of cancer. The prevalence of specific morbidities in patients diagnosed with common and rarer cancers is inadequately described. MethodsUsing data from the English National Cancer Diagnosis Audit 2014, we studied 11 pre-existing morbidities recorded as yes/no items by participating general practitioners based on information included in primary care records. We examined the number and type of morbidities across socio-demographic and cancer site strata, and subsequently estimated observed and age/sex standardised prevalence of each morbidity by cancer. ResultsOver three-quarters (77 %; 11,429/14,774) of non-screen-detected patients had at least one chronic condition before diagnosis, while nearly half (47 %) had two or more. Hypertension (39 %) and physical disability (2%) were the most and least common conditions. Male, older and more socio-economically deprived patients were more likely to have at least one morbidity (p < 0.001 for all between variable group comparisons). For most morbidities, the standardised prevalence was similar across different cancers with a few exceptions, including respiratory disease prevalence being greatest among lung cancer patients and diabetes prevalence being greatest among liver, pancreatic, and endometrial cancer patients. ConclusionsMost cancer patients have at least one morbidity, while almost one in two have two or more. The findings highlight the need to take certain morbidity- and cancer-site combinations into account when examining associations between morbidity and cancer outcomes.

Cancer diagnosis and treatment in the COVID‐19 era

Screening and early symptom-based detection of cancer offer the prospect of diagnosing cancers at a stage where treatment can lead to either prolonged survival or cure. While screening programmes for breast, colorectal and cervical cancer are established in most developed countries, other programmes such as lung cancer screening are also beginning to emerge. We frequently publish papers in EJCC on uptake in cancer screening programmes—if such programmes cannot achieve acceptable levels of uptake in the community, their population health benefits diminish significantly. We also regularly publish papers on promoting early diagnosis—for example through public awareness campaigns and strategies to improve recognition and referral of cancers in primary care. In this issue of the journal, Karakuş Selçuk and Yanikkerem (2019) describe a web-based intervention to improve participation in cervical cancer screening. Like many such interventions, they demonstrate a benefit in this mixed methods study. Cervical cancer is a good example of the ongoing effort that needs to be invested in cancer screening programmes. In recent years, there have been concerns for example in falling rates of cervical screening in the UK (Castanon & Sasieni, 2018). Increasingly, novel methods, such as those described by Karakus et al (2020), are required to maintain participation. This is particularly so, in the case of cervical screening, with the advent of HPV vaccination and testing, which has perceptions about the importance of cervical screening (Patel, Moss, & Sherman, 2018). Also in this issue, Murchie et al. (2020) report on an audit of cancer referrals from primary care in Scotland. This is clearly an important ongoing initiative to monitor such referrals and look for lessons about how primary care can more effectively recognise cancer symptoms and make appropriate referrals. The authors present data on key indicators including cancer referral rates and characteristics of cancers detected. There has, over the last decade, been a great deal of research which has shone a light on the cancer diagnostic process in primary care; we now know a great deal more about how symptoms are assessed and referrals made in primary care (Rubin et al., 2015). For example that cancers with vague symptoms typically have longer intervals (Lyratzopoulos, Neal, Barbiere, Rubin, & Abel, 2012). The data from the National Cancer Diagnosis Audit will be an important ongoing source of cancer intelligence in Scotland. It would be difficult, however, to talk about screening and early diagnosis without acknowledging the profound impact of the COVID-19 epidemic. In the UK and in many other countries, cancer screening has been put on hold—this is likely to have very significant downstream implications. Also, we know that cancer referrals for primary care have dropped very dramatically as both primary and secondary care reorient their focus towards the COVID-19 epidemic. Clearly, there are difficult decisions to be made over COVID-19 and ongoing cancer control efforts; it has transformed every aspect of cancer care and has impacted profoundly on the cancer workforce (Mayor, 2020). It has caused many health planners to think carefully about how they can manage cancer through an epidemic such as this; cancer treatments are profoundly impacted and we know that cancer patients, particularly those receiving chemotherapy, are especially vulnerable to COVID-19—so difficult decisions are needing to be made about treatment decisions for many cancer patients (Al-Shamsi et al., 2020; Vrdoljak, Sullivan, & Lawler, 2020). Modelling studies suggest that there are likely to be excess deaths from cancer based on the current reconfiguration of health service activity; two UK studies which are yet to be published have provided estimates of excess cancer mortality and highlight the need for urgent attention from health planners and policy makers (Alvina et al, 2020; Sud et al., 2020). We urgently need a joined up dialogue about maintaining cancer diagnostic and treatment services whilst addressing the worst aspects of the COVID-19 epidemic. We are at the beginning of a rather steep learning curve, but there can be no doubt that research examining the impact on cancer outcomes is urgently needed if we are to limit the collateral damage from this epidemic. The journal is beginning to receive an increasing number of papers examining these issues, and we urge researchers in this field to keep sending in their submissions.

Impact of geography on Scottish cancer diagnoses in primary care: Results from a national cancer diagnosis audit

BackgroundA recent meta-analysis of global research found cancer patients living in rural locations are 5% less likely to survive than their urban counterparts, a survival disadvantage that has never been satisfactorily explained. Aims[1] To describe and compare primary-care involvement in the diagnosis of cancer between rural and urban patients in Scotland. [2] To compare the length of key diagnostic pathway intervals between rural and urban cancer patients in Scotland. MethodsParticipating GPs in the Scottish National Cancer Audit of cancer diagnosis (2017) collected data from primary-care medical records on the diagnostic pathway of patients diagnosed in 2014. Residential postcodes designated the patients as rural or urban dwellers. Key cancer diagnostic pathway intervals (primary, diagnostic, secondary, and treatment) were compared using binary logistic regression. Descriptive analysis included comparison of patient characteristics, and routes to diagnosis. Results73 Scottish general practices provided data on 1,905 cancer diagnoses. Rural patients did not have higher odds of prolonged diagnostic intervals compared to urban patients but were significantly more likely to have had a cancer alarm feature at presentation and three or more primary-care consultations prior to referral. Rural GPs were significantly more likely to perceive an avoidable delay in their patient’s diagnostic pathway. ConclusionThere was no evidence that rural patients were more likely to be subject to prolonged cancer diagnostic delays than urban patients. Rural patients may experience primary care differently in the lead-up to a cancer diagnosis. The effect on outcome is probably negligible, but further research is required to confirm this.

Cancer diagnosis in Scottish primary care: Results from the National Cancer Diagnosis Audit.

To characterize cancer diagnosis in Scottish primary care and draw comparisons with cancer diagnostic activity in England. A national audit of cancer diagnosis was conducted in Scottish and English general practices. Participating GPs collected diagnostic pathway data on patients diagnosed in 2014 from medical records. Data were supplemented by linkage to national cancer registries. Analysis explored and compared patient characteristics, diagnostic intervals, and routes to diagnosis. 7.7% of all Scottish general practices in 2017 provided data on 2,014 cancer diagnoses. 71.5% of cases presented to GPs and 37.4% were referred using the "Urgent-Suspected Cancer" route. The median primary care interval was 5days (IQR 0-23days) and median diagnostic interval was 30days (IQR 13-68). Both varied by cancer-site. Diagnostic intervals were longer in the most remote patients and those with more comorbidities. Scottish and English samples corresponded closely in key characteristics. Most people diagnosed with cancer in Scotland present to a GP first. Most are referred and diagnosed quickly, with variations by cancer-site. Intervals were longest for the most remote patients. GPs in Scotland and England appear to perform equally but, in view of growing differences between health systems, future comparative audits may be informative.

Cross-sectional study using primary care and cancer registration data to investigate patients with cancer presenting with non-specific symptoms

IntroductionPatients presenting to primary care with site-specific alarm symptoms can be referred onto urgent suspected cancer pathways, whereas those with non-specific symptoms currently have no dedicated referral routes leading to...

The frequency, nature and impact of GP-assessed avoidable delays in a population-based cohort of cancer patients

BackgroundThere is a growing emphasis on the speed of diagnosis as an aspect of cancer prognosis. While epidemiological data in the last decade have quantified diagnostic timeliness and its variation, whether and how often prolonged diagnostic intervals can be considered avoidable is unknown. MethodsWe used data from the English National Cancer Diagnosis Audit (NCDA) on 17,042 patients diagnosed with cancer in 2014. Participating primary care physicians were asked to identify delays in diagnosis that they deemed avoidable, together with the ‘setting’ of the avoidable delay and key attributable factors. We used descriptive analysis and regression frameworks to assess validity and examine variation in the frequency and nature of avoidable delays. ResultsAmong 14,259 patients, 24% were deemed to have had an avoidable delay to their diagnosis. Patients with a reported avoidable delay had a longer median diagnostic interval (92 days) than those without (30 days). Of all avoidable delays, 13% were deemed to have occurred pre-consultation, 49% within primary care, and 38% within secondary care. Avoidable delays were mostly attributed to the test request/performance phase (25%). Multimorbidity was associated with greater odds of avoidable delay (OR for 3+ vs no comorbidity: 1.43 (95% CI 1.25–1.63)), with heterogeneous associations with cancer site. ConclusionWe have shown that GP-identified instances of avoidable delay have construct validity. Whilst the causes of avoidable diagnostic delays are multi-factorial and occur in different settings and phases of the diagnostic process, their analysis can guide improvement initiatives and enable the examination of any prognostic implications.

Presenting symptoms of cancer and stage at diagnosis: evidence from a cross-sectional, population-based study.

SummaryBackgroundEarly diagnosis interventions such as symptom awareness campaigns increasingly form part of global cancer control strategies. However, these strategies will have little impact in improving cancer outcomes if the targeted symptoms represent advanced stage of disease. Therefore, we aimed to examine associations between common presenting symptoms of cancer and stage at diagnosis.MethodsIn this cross-sectional study, we analysed population-level data from the English National Cancer Diagnosis Audit 2014 for patients aged 25 years and older with one of 12 types of solid tumours (bladder, breast, colon, endometrial, laryngeal, lung, melanoma, oral or oropharyngeal, ovarian, prostate, rectal, and renal cancer). We considered 20 common presenting symptoms and examined their associations with stage at diagnosis (TNM stage IV vs stage I–III) using logistic regression. For each symptom, we estimated these associations when reported as a single presenting symptom and when reported together with other symptoms.FindingsWe analysed data for 7997 patients. The proportion of patients diagnosed with stage IV cancer varied substantially by presenting symptom, from 1% (95% CI 1–3; eight of 584 patients) for abnormal mole to 80% (71–87; 84 of 105 patients) for neck lump. Three of the examined symptoms (neck lump, chest pain, and back pain) were consistently associated with increased odds of stage IV cancer, whether reported alone or with other symptoms, whereas the opposite was true for abnormal mole, breast lump, postmenopausal bleeding, and rectal bleeding. For 13 of the 20 symptoms (abnormal mole, breast lump, post-menopausal bleeding, rectal bleeding, lower urinary tract symptoms, haematuria, change in bowel habit, hoarseness, fatigue, abdominal pain, lower abdominal pain, weight loss, and the “any other symptom” category), more than 50% of patients were diagnosed at stages other than stage IV; for 19 of the 20 studied symptoms (all except for neck lump), more than a third of patients were diagnosed at stages other than stage IV.InterpretationDespite specific presenting symptoms being more strongly associated with advanced stage at diagnosis than others, for most symptoms, large proportions of patients are diagnosed at stages other than stage IV. These findings provide support for early diagnosis interventions targeting common cancer symptoms, countering concerns that they might be simply expediting the detection of advanced stage disease.FundingUK Department of Health's Policy Research Unit in Cancer Awareness, Screening and Early Diagnosis; and Cancer Research UK.

Incidentally diagnosed cancer and commonly preceding clinical scenarios: a cross-sectional descriptive analysis of English audit data

ObjectivesCancer can be diagnosed in the absence of tumour-related symptoms, but little is known about the frequency and circumstances preceding such diagnoses which occur outside participation in screening programmes. We...

National Cancer Diagnosis Audit: avoidable delays to diagnosis

BackgroundA prolonged time taken to diagnose cancer can lead to poorer survival and reduced quality of life. Characterising avoidable delays to a patient’s diagnosis could help to direct quality improvement initiatives aimed at enhancing patient safety and ultimately patient outcomes.AimTo assess the validity of data on avoidable delays collected as part of the English National Cancer Diagnosis Audit (NCDA) and to estimate the predictors of avoidable delays to diagnosis by patient demographics and cancer type.MethodParticipating general practices (n = 439; 5% practices) submitted primary care data on patients (n = 17 042) diagnosed with cancer in 2014 in England. GPs reported delays to the diagnosis that they considered avoidable. Quantile regression was used to understand the impact of an avoidable delay on the diagnostic interval. Logistic regression models were used to investigate the factors associated with avoidable delay.ResultsThe GP recorded an avoidable delay to cancer diagnosis in 24% of cases (n = 3372). The median diagnostic interval was 57 days longer in patients where an avoidable delay was recorded. Results have shown significant associations between avoidable delay and certain cancer types (odds ratio [OR] 1.73 for stomach versus lung cancer) and an increasing number of comorbidities (OR 1.43 for patients with ≥3 versus 0).ConclusionGP-reported data showed a longer diagnostic interval in patients thought to have had an avoidable delay to their diagnosis, indicating construct validity of the data collected. Data from the NCDA is being used to better understand avoidable delays to diagnosis, and identify possible solutions for improving the diagnostic pathway in some cases.

National Cancer Diagnosis Audit: initial results on avoidable delays

BackgroundAn earlier diagnosis of cancer can increase cancer survival and quality of life. Characterising avoidable delays to a patient’s diagnosis of cancer can help to direct quality improvement initiatives.AimTo evaluate avoidable delays to cancer diagnoses and the variation by cancer type and patient characteristics using primary care data collected as part of the National Cancer Diagnosis Audit (NCDA).MethodEnglish general practices participating in the NCDA (439) entered primary care data on patients (17,042) diagnosed with cancer in 2014. Using a taxonomy developed from the National Audit of Cancer Diagnosis in Primary Care (2011), GPs reported delays to the diagnosis that in their judgement were avoidable.ResultsIn 22% of NCDA patient records (n = 3380), the GP considered there to be an avoidable delay to the patient receiving their cancer diagnosis. There was variation by cancer type; 7% of breast cancer patients experienced delays compared to 34% of stomach cancer patients. 49% of avoidable delays occurred in primary care and 38% in secondary or tertiary care. Of all delays, 28% were attributed to clinician factors and 34% to health care system factors. Results will be presented by patient characteristics.ConclusionPrimary care data from the NCDA can be used to better understand potentially avoidable delays to diagnosis and identify possible solutions for improving the diagnostic pathway. Avoidable delays during cancer diagnosis occur for many reasons. These insights can inform quality improvement initiatives, which should be directed at both clinical and organisational factors in primary care and hospital settings.

Symptoms in primary care with time to diagnosis of brain tumours.

BackgroundBrain tumours often present with varied, non-specific features with other diagnoses usually being more likely.ObjectiveTo examine how different symptoms and patient demographics predict variations in time to brain tumour diagnosis.MethodsWe conducted a secondary analysis of brain tumour cases from National Audit of Cancer Diagnosis in Primary Care. We grouped neurological symptoms into six domains (headache, behavioural/cognitive change, focal neurology, ‘fits, faints or falls’, non-specific neurological, and other/non-specific) and calculated times for patient presentation, GP referral, specialist consultation and total pathway interval. We calculated odds ratios (ORs) for symptom domains comparing the slowest to other quartiles.ResultsData were available for 226 cases. Median (interquartile range) time for the total pathway interval was 24 days (7–65 days). The most common presentation was focal neurology (33.2%) followed by ‘fits, faints or falls’ and headache (both 20.8%). Headache only (OR = 4.11, 95% CI = 1.10, 15.5) and memory complaints (OR = 4.82, 95% CI = 1.15, 20.1) were associated with slower total pathway compared to ‘fits, faints or falls’. GPs were more likely to consider that there had been avoidable delays in referring patients with headache only (OR = 4.17, 95% CI = 1.14, 15.3).ConclusionPatients presenting to primary care with headache only or with memory complaints remain problematic with potentially avoidable delays in referral leading to a longer patient pathway. This may or may not impact on the efficacy and morbidity of therapies. Additional aids are required to help doctors differentiate when to refer headaches and memory complaints urgently for a specialist opinion.

The nature and frequency of abdominal symptoms in cancer patients and their associations with time to help-seeking: evidence from a national audit of cancer diagnosis.

BackgroundRaising awareness of possible cancer symptoms is important for timely help-seeking; recent campaigns have focused on symptom groups (such as abdominal symptoms) rather than individual alarm symptoms associated with particular cancer sites. The evidence base supporting such initiatives is still emerging however; understanding the frequency and nature of presenting abdominal symptoms among cancer patients could inform the design and evaluation of public health awareness campaigns.MethodsWe examined eight presenting abdominal symptoms (abdominal pain, change in bowel habit, bloating/distension, dyspepsia, rectal bleeding, dysphagia, reflux and nausea/vomiting) among 15 956 patients subsequently diagnosed with cancer in England. We investigated the cancer site case-mix and variation in the patient interval (symptom-onset-to-presentation) by abdominal symptom.ResultsAlmost a quarter (23%) of cancer patients presented with abdominal symptoms before being diagnosed with one of 27 common and rarer cancers. The patient interval varied substantially by abdominal symptom: median (IQR) intervals ranged from 7 (0–28) days for abdominal pain to 30 (4–73) days for dysphagia. This variation persisted after adjusting for age, sex and ethnicity (P < 0.001).ConclusionsAbdominal symptoms are common at presentation among cancer patients, while time to presentation varies by symptom. The need for awareness campaigns may be greater for symptoms associated with longer intervals to help-seeking.

Diagnosing cancer in primary care: results from the National Cancer Diagnosis Audit.

BackgroundContinual improvements in diagnostic processes are needed to minimise the proportion of patients with cancer who experience diagnostic delays. Clinical audit is a means of achieving this.AimTo characterise key aspects of the diagnostic process for cancer and to generate baseline measures for future re-audit.Design and settingClinical audit of cancer diagnosis in general practices in England.MethodInformation on patient and tumour characteristics held in the English National Cancer Registry was supplemented by information from GPs in participating practices. Data items included diagnostic timepoints, patient characteristics, and clinical management.ResultsData were collected on 17 042 patients with a new diagnosis of cancer during 2014 from 439 practices. Participating practices were similar to non-participating ones, particularly regarding population age, urban/rural location, and practice-based patient experience measures. The median diagnostic interval for all patients was 40 days (interquartile range [IQR] 15–86 days). Most patients were referred promptly (median primary care interval 5 days [IQR 0–27 days]). Where GPs deemed diagnostic delays to have occurred (22% of cases), patient, clinician, or system factors were responsible in 26%, 28%, and 34% of instances, respectively. Safety netting was recorded for 44% of patients. At least one primary care-led investigation was carried out for 45% of patients. Most patients (76%) had at least one existing comorbid condition; 21% had three or more.ConclusionThe findings identify avenues for quality improvement activity and provide a baseline for future audit of the impact of 2015 National Institute for Health and Care Excellence guidance on management and referral of suspected cancer.

Typical and atypical presenting symptoms of breast cancer and their associations with diagnostic intervals: Evidence from a national audit of cancer diagnosis

IntroductionMost symptomatic women with breast cancer have relatively short diagnostic intervals but a substantial minority experience prolonged journeys to diagnosis. Atypical presentations (with symptoms other than breast lump) may be responsible. MethodsWe examined the presenting symptoms of breast cancer in women using data from a national audit initiative (n=2316). Symptoms were categorised topographically. We investigated variation in the length of the patient interval (time from symptom onset to presentation) and the primary care interval (time from presentation to specialist referral) across symptom groups using descriptive analyses and quantile regression. ResultsA total of 56 presenting symptoms were described: breast lump was the most frequent (83%) followed by non-lump breast symptoms, (e.g. nipple abnormalities (7%) and breast pain (6%)); and non-breast symptoms (e.g. back pain (1%) and weight loss (0.3%)).Greater proportions of women with ‘non-lump only’ and ‘both lump and non-lump’ symptoms waited 90days or longer before seeking help compared to those with ‘breast lump only’ (15% and 20% vs. 7% respectively). Quantile regression indicated that the differences in the patient interval persisted after adjusting for age and ethnicity, but there was little variation in primary care interval for the majority of women. ConclusionsAbout 1 in 6 women with breast cancer present with a large spectrum of symptoms other than breast lump. Women who present with non-lump breast symptoms tend to delay seeking help. Further emphasis of breast symptoms other than breast lump in symptom awareness campaigns is warranted.