Referral Cancer Research Articles

Delayed cancer referrals: Who is accountable?

Practice ManagementVol. 31, No. 3 Editor's WordDelayed cancer referrals: Who is accountable?Polly MoffatPolly MoffatEditorSearch for more papers by this authorPolly MoffatPublished Online:12 Mar 2021https://doi.org/10.12968/prma.2021.31.3.5AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail View article

Telephone triage of suspected head and neck cancer patients during the coronavirus disease 2019 pandemic using the Head and Neck Cancer Risk Calculator version 2.

Utilisation of the Head and Neck Cancer Risk Calculator version 2 has been recommended during the coronavirus disease 2019 pandemic for the assessment of head and neck cancer referrals. As limited data were available, this study was conducted to analyse the use of the Head and Neck Cancer Risk Calculator version 2 in clinical practice. Patients undergoing telephone triage in a two-week wait referral clinic were included. Data were collected and analysed using appropriate methods. Sixty-four patients in the study were risk-stratified into low-risk (51.6 per cent, 33 of 64), moderate-risk (14.1 per cent, 9 of 64) and high-risk (34.4 per cent, 22 of 64) groups. Of the patients, 53.1 per cent (34 of 64) avoided an urgent hospital visit, and 96.9 per cent (62 of 64) were cancer free, while 3.1 per cent (2 of 64) were found to have a head and neck malignancy. The sensitivity, specificity, negative predictive value and accuracy were 50.00 per cent, 66.13 per cent, 99.92 per cent and 66.11 per cent, respectively. It is reasonable to use the calculator for triaging purposes, but it must always be accompanied by a meticulous clinical thought process.

A study demonstrating the accuracy of a new triage system for breast cancer referrals during the Covid-19 pandemic in a tertiary hospital.

Background: The Covid-19 pandemic has led to a need for alternative methods of doctor-patient communication. Most healthcare providers have utilised telecommunication to minimise face-to-face contact whilst continuing to provide essential services. At our institution, patients are being triaged by consultant breast surgeons to clinic or phone/video consultation on the basis of the referral letter. This triage system has gradually changed as the pandemic situation stabilised, with more emphasis placed on patient risk factors.

Patterns of urgent hoarseness referrals to ENT-When should we be suspicious of cancer?

Current UK referral criteria stipulate that hoarseness should be persistent to merit 2week wait (2WW) or urgent suspicion of cancer (USOC) referral. This study delineates patterns of hoarseness presentation with a view to assisting referral pathways, and whereby reassurance could be provided. A pre-existing database of patients referred with hoarseness under the urgent suspicion of cancer (USOC) category was analysed. Univariate and multivariate analyses were performed on a variety of demographic and comorbid features to produce odds ratios (OR) of features either related or not related to laryngeal cancer. Of 698 consecutive hoarseness referrals were studied. In these referrals there were 506(73%) with persistent hoarseness and 192(27%) with intermittent hoarseness. The most significant patient variables related to laryngeal cancer were persistent hoarseness (OR 4.97), recreational drug use (OR 4.94), male gender (OR 4.01) and weight loss (OR 3.75). Significant patient variables present not related to laryngeal cancer diagnosis were intermittent hoarseness (OR 0.2), the presence of cough (OR 0.2), globus sensation (OR 0.25) and recent viral infection (OR 0.29). The strongest association with cancer is seen in patients that are persistently hoarse. Patients with fluctuating hoarseness do not need an "urgent suspicion of cancer" referral. Additional demographic referral information could help to streamline the referral of these patients, and reassure others.

Remote Triage Incorporating Symptom-Based Risk Stratification for Suspected Head and Neck Cancer Referrals: A Prospective Population-Based Study

Remote Triage Incorporating Symptom-Based Risk Stratification for Suspected Head and Neck Cancer Referrals: A Prospective Population-Based Study

A study demonstrating the accuracy of a new triage system for breast cancer referrals during the Covid-19 pandemic in a tertiary hospital

Introduction: The Covid-19 pandemic necessitated innovative patient communication to minimise face-to-face contact yet allow essential services. At our institution, referrals are triaged by consultant breast surgeons to clinic, phone or video consultation. As the pandemic stabilised, less emphasis was placed on patients’ comorbidities. This study aims to demonstrate the accuracy of this process at a tertiary hospital.

A colorectal straight-to-test cancer pathway with general-practitioner-guided triage improves attainment of the 28-day diagnosis target and increases outpatient clinic capacity.

This study investigates whether a straight-to-test (STT) colorectal cancer pathway improves attainment of the National Health Service (NHS) England 28-day Faster Diagnosis Standard and the effect of the pathway on reducing face-to-face outpatient clinic appointments. Patient satisfaction and the safety of a novel general practitioner (GP) led patient triage system regarding suitability for colonoscopy are also evaluated. This is an observational study of all patients managed via an STT colorectal cancer pathway between 1 September 2019 and 19 March 2020. Comparison is made with all patients referred on the suspected colorectal cancer pathway prior to implementation of the STT pathway from 1 January 2019 to 30 July 2019. Patient satisfaction with the STT pathway was assessed with a telephone-based questionnaire. Attainment of the 28-day diagnosis target for all suspected colorectal cancer referrals improved following the establishment of the STT pathway (88% vs. 82%, P<0.0001). From a potential total of 548 outpatient colorectal clinic appointments for patients on the STT pathway, 504 (92%) were avoided. In those eligible for the STT pathway, GP assessment of patients suitable for colonoscopy agreed with that of the colorectal department in 93% of cases. Of the 50 patients who undertook the satisfaction survey, 86% were satisfied or very satisfied with the pathway. No patient suffered adverse events as a result of their STT investigations. An STT pathway for suspected colorectal cancer referrals with novel GP-led patient triage safely streamlines patients through the suspected colorectal cancer diagnostic pathway and significantly reduces requirement for face-to-face outpatient clinic attendance. This is achieved with high patient satisfaction.

Identification of Incidental Skin Cancers Among Adults Referred to Dermatologists for Suspicious Skin Lesions

The incidence of skin cancer is increasing and evaluation of the utility of total body skin examination (TBSE) in detecting incidental skin cancers is warranted. To evaluate the proportion and rate of incidental skin cancer detection in urgent skin cancer clinics and investigate the rate of incidental skin cancer detection in 2 groups based on the degree of clinical suspicion of the index lesion for malignancy. A multicenter retrospective cohort study with a case note review of consecutive secondary care consultations was conducted using data from 2 urgent suspected skin cancer screening clinics in UK National Health Service trusts. The study was performed from January 1, 2015, to March 31, 2016, and data analysis was performed from October 14, 2018, to February 1, 2019. Patients included those presenting with a skin lesion suspicious of malignancy who were referred to the urgent suspected skin cancer clinic (N = 5944) over 15 months. Patients who accepted and received a TBSE were subsequently included in the analysis. The proportion and rate of incidental skin cancer detection through TBSE and whether a clinically suspicious (malignant) index lesion was associated with a higher chance of having a malignant incidental lesion. Of the 5944 patients referred to the clinic, 4726 individuals (79.5%) were evaluated. In the cohort included in the analyses, the median age was 57 years (interquartile range, 39-73 years); 2567 patients (54.3%) were women. A total of 1117 skin cancers were identified; of these, 242 lesions (21.7%) were detected incidentally through TBSE, including 197 of 570 (34.6%) basal cell carcinomas, 16 of 250 (6.4%) squamous cell carcinomas, and 25 of 215 (11.6%) melanomas. The detection rate of incidental malignant lesions was 5.1 lesions per 100 patients examined (5.1%; 95% CI, 4.5%-5.8%). There was a higher detection rate of histologically confirmed incidental malignant lesions in individuals with clinically suspicious index lesions requiring biopsy (10.9%; 95% CI, 9.5%-12.5%) compared with those presenting with clinically benign index lesions (2.0%; 95% CI, 1.6%-2.5%) (P < .001). The findings of this study support the use of TBSE for urgent skin cancer referrals, highlighting the potential harms of solitary lesion assessment in a subgroup. Individuals presenting with a clinically suspicious index lesion requiring biopsy are most likely to benefit from TBSE and should be counseled regarding the benefit.

The power of personal care: the value of the patient-GP consultation.

The COVID-19 pandemic has resulted in a dramatic shift from face-to-face to remote consulting within general practice. There have been some important gains in terms of travelling for patients and flexible working for general practice teams. However, there have been losses too. Urgent GP cancer referrals were estimated to be at 42% in April 2020 compared with the year before.1 Digital-first approaches, now widespread, can paradoxically increase overall GP workload and a recent study warns of extra GP work by up to a third.2 Vigilance and open minds are needed. As we move forward and while preparing for a busy winter, it is timely to decide which changes should be kept and under what conditions. Research has illuminated the considerable value of the human side of general practice. Over 20 years ago we learned that longer consultations and the patient knowing the GP are significantly associated with enablement — an important outcome …

The experience of UK patients with bladder cancer during the COVID-19 pandemic: a survey-based snapshot.

The COVID-19 pandemic has placed unprecedented strain on healthcare systems worldwide with the requirement to treat large influxes of infected patients, many of whom require respiratory support. Healthcare systems have had to redirect resources and redeploy staff away from routine diagnostic, treatment and follow-up services. The UK's National Health Service (NHS) is no different and cancer services have undergone significant disruption to create the emergency capacity to tackle the pandemic. As a charity that endeavours to support bladder cancer (BC) patients and improve outcomes, Action Bladder Cancer UK (ABCUK, Tetbury, UK) designed and administered an online survey to investigate the prevalence of such disruption.

Patient Delay and Contributing Factors Among Breast Cancer Patients at Two Cancer Referral Centres in Ethiopia: A Cross-Sectional Study.

BackgroundUnlike developed countries, there is high mortality of breast cancer in low- and middle-income countries associated with prolonged patient delays and advanced stage presentations. However, evidence-based information about patient delay in presentation and contributing factors to diagnosis of breast cancer in Ethiopia is scarce.MethodsInstitution-based cross-sectional study was conducted at oncology units of the University of Gondar and Felege Hiwot specialized hospitals. A total of 371 female breast cancer patients who were newly diagnosed from September 2019 to April 30, 2020 were included. Data were entered using EPI info version 7.2 and analyzed in SPSS version 23. Descriptive statistics was used to summarize socio-demographic and clinical characteristic of the patients. Multivariable logistic regression at a P-value<0.05 significance level was used to identify predictors of patient delay.ResultsA total of 281 (75.7%) patients had long patient delay of ≥90 days (3 months) with the average patient delay time of 8 months, and advanced stage diagnosis was found on 264 (71.2%) of patients. The median age of patients was 40 years. Rural residence (AOR=3.72; 95% CI=1.82–7.61), illiterate (AOR=3.8; 95% CI=1.71–8.64), having a painless wound (AOR=3.32; 95% CI=1.93, 5.72), travel distance ≥5 km (AOR=1.66; 95% CI=1.09–3.00), having no lump/swelling in the armpit (AOR=6.16; 95% CI=2.80–13.54), and no history of any breast problem before (AOR=2.46; 95% CI=(1.43–4.22) were predictors for long patient delay.ConclusionLong patient delay and advanced stage diagnosis of breast cancer are higher in our study. Travel distance ≥5 km, rural residence, no history of any breast problem before, having no lump/swelling in the arm pit, a painless lump in the breast, and being illiterate were important predictors for patient delay. Therefore, public awareness programs about breast cancer should be designed to prevent patient delay in presentation and to promote early detection of cases before advancement.

Race, not socioeconomic disparities, correlates with survival in human papillomavirus-negative oropharyngeal cancer: A retrospective study

PurposeInvestigate the impact of black versus white race, socioeconomic status (SES), and comorbidity burden on oropharyngeal cancer (OPC) survival. Materials and methodsThis study retrospectively analyzed patients diagnosed between 1991 and 2012 at an urban tertiary care center with a high volume of head and neck cancer referrals. Data gathered included demographics, human papilloma virus (HPV) status, follow-up time, comorbidities, smoking history, and overall survival. SES was extrapolated from the 2000 and 2010 censuses. Analysis of variance, chi-square tests, multivariable Cox proportional hazards models, Cox proportional hazards regression, Kaplan Meier curves and the log-rank test were utilized. ResultsOf 208 charts reviewed, 192 patients met inclusion criteria. Black patients had significantly (p < 0.001) poorer survival at 1, 2, and 5 years than white patients (5-year survival: 32% vs 64%); this discrepancy persisted in only HPV-negative disease (20% vs 50%). In the HPV-negative subgroup, there was no racial difference in treatment modality received, Charlson Comorbidity Index, and proportion receiving inadequate, noncurative or no treatment. Univariate analysis identified significant differences in median household income, education level, and stage at presentation between black and white subgroups. Multivariate analysis identified white race and HPV-positive status as independent predictors of overall survival, but SES and stage at presentation were not. ConclusionSES did not explain the greater survival in HPV-negative white versus black patients. This indicates that race is an independent predictor of survival; future studies should examine more accurate indicators of SES and genetic differences in tumors of black and white patients.

Assessment of awareness of oral cancer among nursing students at BPKIHS, Nepal

Background: Early recognition of oral cancer is essential for higher cure rate and better prog­nosis. Nurses can play a significant role in the early diagnosis of cancers. The study aimed to assess the awareness of oral cancer among nursing students. &#x0D; Methods: A cross-sectional survey was conducted among Bachelor of Nursing Students at College of Nursing, B.P. Koirala Institute of Health Sciences. A semi-structured questionnaire was used to collect the sociodemographic data and awareness of cancer. Descriptive statistics were calculated using Statistical Package for Social Sciences version 22.0. &#x0D; Results: Out of 116, 89 (76.7%) students were of age 21-25 years. One hundred and twelve stu­dents (96.6%) were aware that various form of tobacco increases risk of oral cancer; however, only 55 (47.4%) students knew alcohol drinking as a risk factor. Only 29 (25.0%) students were aware of loose-fitting denture as a risk factor for oral cancer. Ninety-six (82.8%) students knew white or red patch as possible signs of oral cancer; however, only six (5.2%) students were aware of the most common site of oral cancer. Only 16 (13.8%) students considered that they are adequately trained to screen oral cancer. One hundred and fifteen (99.1%) students demanded more education on oral cancer. &#x0D; Conclusions: This study revealed that nursing students’ awareness of risk factors and the impor­tance of screening of oral cancer is suboptimal. It highlights a need for basic education on oral can­cer to make them more aware and further competent toward oral cancer screening and referral.

ASSESSMENT OF AWARENESS OF ORAL CANCER AMONG NURSING STUDENTS AT BPKIHS, NEPAL

Background: Early recognition of oral cancer is essential for higher cure rate and better prog­nosis. Nurses can play a significant role in the early diagnosis of cancers. The study aimed to assess the awareness of oral cancer among nursing students. Methods: A cross-sectional survey was conducted among Bachelor of Nursing Students at College of Nursing, B.P. Koirala Institute of Health Sciences. A semi-structured questionnaire was used to collect the sociodemographic data and awareness of cancer. Descriptive statistics were calculated using Statistical Package for Social Sciences version 22.0. Results: Out of 116, 89 (76.7%) students were of age 21-25 years. One hundred and twelve stu­dents (96.6%) were aware that various form of tobacco increases risk of oral cancer; however, only 55 (47.4%) students knew alcohol drinking as a risk factor. Only 29 (25.0%) students were aware of loose-fitting denture as a risk factor for oral cancer. Ninety-six (82.8%) students knew white or red patch as possible signs of oral cancer; however, only six (5.2%) students were aware of the most common site of oral cancer. Only 16 (13.8%) students considered that they are adequately trained to screen oral cancer. One hundred and fifteen (99.1%) students demanded more education on oral cancer. Conclusions: This study revealed that nursing students’ awareness of risk factors and the impor­tance of screening of oral cancer is suboptimal. It highlights a need for basic education on oral can­cer to make them more aware and further competent toward oral cancer screening and referral.

Improving early cancer diagnosis in primary care

Primary healthcare professionals are in a vital position to help reduce delays to cancer diagnosis, as they can encourage participation in cancer screening programmes and patients often present to their GP practice with symptoms prior to diagnosis. This article discusses some of the measures that can be taken to increase uptake of cancer screening, raise awareness of symptoms of possible cancer, and help identify which patients may benefit from an urgent cancer referral.

COVID-19 pandemic in the United Kingdom

ObjectivesTo describe epidemiological data on cases of COVID-19 and the spread of Severe Acute Respiratory Syndrome Coronavirus 2 in the United Kingdom (UK), and the subsequent policy and technological response to the pandemic, including impact on healthcare, business and the economy. MethodsEpidemiological, business and economic data were extracted from official government sources covering the period 31st January to 13th August 2020; healthcare system data up to end of June 2019. ResultsUK-wide COVID-19 cases and deaths were 313,798 and 46,706 respectively (472 cases and 70 deaths per 100,000 population) by 12th August. There were regional variations in England, with London and North West (756 and 666 cases per 100,000 population respectively) disproportionately affected compared with other regions. As of 11th August, 13,618,470 tests had been conducted in the UK. Increased risk of mortality was associated with age (≥60 years), gender (male) and BAME groups. Since onset of the pandemic, emergency department attendance, primary care utilisation and cancer referrals and inpatient/outpatient referrals have declined; emergency ambulance and NHS111 calls increased. Business sectors most impacted are the arts, entertainment and recreation, followed by accommodation and food services. Government interventions aimed at curtailing the business and economic impact have been implemented, but applications for state benefits have increased. ConclusionsThe impact of COVID-19 on the UK population, health system and economy has been profound. More data are needed to implement the optimal policy and technological responses to preventing further spikes in COVID-19 cases, and to inform strategic planning to manage future pandemics.

Effect of delays in the 2-week-wait cancer referral pathway during the COVID-19 pandemic on cancer survival in the UK: a modelling study.

BackgroundDuring the COVID-19 lockdown, referrals via the 2-week-wait urgent pathway for suspected cancer in England, UK, are reported to have decreased by up to 84%. We aimed to examine the impact of different scenarios of lockdown-accumulated backlog in cancer referrals on cancer survival, and the impact on survival per referred patient due to delayed referral versus risk of death from nosocomial infection with severe acute respiratory syndrome coronavirus 2.MethodsIn this modelling study, we used age-stratified and stage-stratified 10-year cancer survival estimates for patients in England, UK, for 20 common tumour types diagnosed in 2008–17 at age 30 years and older from Public Health England. We also used data for cancer diagnoses made via the 2-week-wait referral pathway in 2013–16 from the Cancer Waiting Times system from NHS Digital. We applied per-day hazard ratios (HRs) for cancer progression that we generated from observational studies of delay to treatment. We quantified the annual numbers of cancers at stage I–III diagnosed via the 2-week-wait pathway using 2-week-wait age-specific and stage-specific breakdowns. From these numbers, we estimated the aggregate number of lives and life-years lost in England for per-patient delays of 1–6 months in presentation, diagnosis, or cancer treatment, or a combination of these. We assessed three scenarios of a 3-month period of lockdown during which 25%, 50%, and 75% of the normal monthly volumes of symptomatic patients delayed their presentation until after lockdown. Using referral-to-diagnosis conversion rates and COVID-19 case-fatality rates, we also estimated the survival increment per patient referred.FindingsAcross England in 2013–16, an average of 6281 patients with stage I–III cancer were diagnosed via the 2-week-wait pathway per month, of whom 1691 (27%) would be predicted to die within 10 years from their disease. Delays in presentation via the 2-week-wait pathway over a 3-month lockdown period (with an average presentational delay of 2 months per patient) would result in 181 additional lives and 3316 life-years lost as a result of a backlog of referrals of 25%, 361 additional lives and 6632 life-years lost for a 50% backlog of referrals, and 542 additional lives and 9948 life-years lost for a 75% backlog in referrals. Compared with all diagnostics for the backlog being done in month 1 after lockdown, additional capacity across months 1–3 would result in 90 additional lives and 1662 live-years lost due to diagnostic delays for the 25% backlog scenario, 183 additional lives and 3362 life-years lost under the 50% backlog scenario, and 276 additional lives and 5075 life-years lost under the 75% backlog scenario. However, a delay in additional diagnostic capacity with provision spread across months 3–8 after lockdown would result in 401 additional lives and 7332 life-years lost due to diagnostic delays under the 25% backlog scenario, 811 additional lives and 14 873 life-years lost under the 50% backlog scenario, and 1231 additional lives and 22 635 life-years lost under the 75% backlog scenario. A 2-month delay in 2-week-wait investigatory referrals results in an estimated loss of between 0·0 and 0·7 life-years per referred patient, depending on age and tumour type.InterpretationPrompt provision of additional capacity to address the backlog of diagnostics will minimise deaths as a result of diagnostic delays that could add to those predicted due to expected presentational delays. Prioritisation of patient groups for whom delay would result in most life-years lost warrants consideration as an option for mitigating the aggregate burden of mortality in patients with cancer.FundingNone.

Two-week rule: suspected head and neck cancer referrals from a general medical practice perspective.

The two-week rule (2WR) referral system was designed to fast-track patients with suspected malignancies to secondary care services to facilitate prompt investigation and management, the ultimate goals being early detection and improved survival. Patients with symptoms of head and neck cancer primarily present to the general practitioner (GP) who has an important role in the identification of high-risk patients for prompt management. This paper reports urgent 2WR referrals from primary care to highlight difficulties in the referral process. Data were collected from three GP practices (16 GPs) in Merseyside that all used the EMIS Web system (EMIS Health). All patients who were referred on the 2WR pathway in a two-year period from January 2017 were identified (n=113). The conversion rate for malignant diagnosis was 5.5% (95% CI: 2.0 to 11.5%). Those with multiple symptoms had a higher rate of malignancy (16%, 3/19) than those with a single symptom (3%, 3/91) (p=0.06). In total, 76% of patients had had no treatment before referral. The duration of symptoms ranged from 1 - 208 weeks (median (IQR) 6 (4-12) weeks). Common benign symptoms included laryngopharyngeal reflux (n=27), thyroid lesion (n=9), and neck lymph node (n=7). The diagnosis of head and neck cancer in primary care is challenging. Initiatives to try to increase the cancer conversion rate are required, but they run the risk of missed diagnosis and increased delay. Sufficient resources are needed in secondary care to ensure the timely assessment of patients who are referred on the 2WR pathway.

Examination Of Pre-surgical Allied Health Referrals In Cancer Patients At A Regional Australian Hospital.

There has been a recent international call to action for key stakeholders to create the infrastructure and cultural adaptations needed so that all people living with and beyond cancer can be as active as is possible. Among the reasons for this is a lack of clarity on the part of those who work in oncology clinical settings of their role in assessing, advising, and referring patients to exercise. PURPOSE: To conduct a retrospective sample audit of allied health referral for breast, prostate and colorectal cancer diagnoses scheduled for surgery. METHODS: A SQUIRE compliant retrospective study was conducted on a representative sample of electronic medical record (EMR) data harvested from the files of (n=100) patients diagnosed with either breast, colorectal and prostate cancer and scheduled for surgery at a regional hospital in Victoria, Australia. Association between ‘time in surgery’ (mins-1) and number Allied Health (exercise physiology) sessions were performed using Pearson product-moment correlation. RESULTS: 62% of cancer referrals attended at least one allied health appointment. Bivariate comparison of referral to allied health revealed strong: prostate (r2=0.78), small/moderate: breast (r2=0.24), and no (r2=0.07) association between surgical time and frequency of allied health attendance amongst cancer diagnoses requiring surgery. CONCLUSIONS: Preliminary results from a small sample of pre-surgical exercise physiology referrals, indicate that breast, and prostate cancer diagnoses requiring surgery can achieve benefit from compliance with referral to Allied Health session, whereas colorectal cancer diagnoses are less clear.

Resource optimization for cancer pathways with aggregate diagnostic demand: a perishable inventory approach.

This work proposes a novel framework for planning the capacity of diagnostic tests in cancer pathways that considers the aggregate demand of referrals from multiple cancer specialties (sites). The framework includes an analytic tool that recursively assesses the overall daily demand for each diagnostic test and considers general distributions for both the incoming cancer referrals and the number of required specific tests for any given patient. By disaggregating the problem with respect to each diagnostic test, we are able to model the system as a perishable inventory problem that can be solved by means of generalized G/D/C queuing models, where the capacity [Formula: see text] is allowed to vary and can be seen as a random variable that is adjusted according to prescribed performance measures. The approach aims to provide public health and cancer services with recommendations to align capacity and demand for cancer diagnostic tests effectively and efficiently. Our case study illustrates the applicability of our methods on lung cancer referrals from UK's National Health Service.