Cancer-specific variation in emergency presentation by sex, age and deprivation across 27 common and rarer cancers.

BACKGROUND: Although overall sociodemographic and cancer site variation in the risk of cancer diagnosis through emergency presentation has been previously described, relatively little is known about how this risk may vary differentially by sex, age and deprivation group between patients with a given cancer. METHODS: Data from the Routes to Diagnosis project on 749,645 patients (2006-2010) with any of 27 cancers that can occur in either sex were analysed. Crude proportions and crude and adjusted odds ratios were calculated for emergency presentation, and interactions between sex, age and deprivation with cancer were examined. RESULTS: The overall proportion of patients diagnosed through emergency presentation varied greatly by cancer. Compared with men, women were at greater risk for emergency presentation for bladder, brain, rectal, liver, stomach, colon and lung cancer (e.g., bladder cancer-specific odds ratio for women vs men, 1.50; 95% CI 1.39-1.60), whereas the opposite was true for oral/oropharyngeal cancer, lymphomas and melanoma (e.g., oropharyngeal cancer-specific odds ratio for women vs men, 0.49; 95% CI 0.32-0.73). Similarly, younger patients were at higher risk for emergency presentation for acute leukaemia, colon, stomach and oesophageal cancer (e.g., colon cancer-specific odds ratio in 35-44- vs 65-74-year-olds, 2.01; 95% CI 1.76-2.30) and older patients for laryngeal, melanoma, thyroid, oral and Hodgkin's lymphoma (e.g., melanoma specific odds ratio in 35-44- vs 65-74-year-olds, 0.20; 95% CI 0.12-0.33). Inequalities in the risk of emergency presentation by deprivation group were greatest for oral/oropharyngeal, anal, laryngeal and small intestine cancers. CONCLUSIONS: Among patients with the same cancer, the risk for emergency presentation varies notably by sex, age and deprivation group. The findings suggest that, beyond tumour biology, diagnosis through an emergency route may be associated both with psychosocial processes, which can delay seeking of medical help, and with difficulties in suspecting the diagnosis of cancer after presentation.We acknowledge the authors of previous studies that led to the creation and curation of the Routes to Diagnosis project and data set. The work presented here is a collaboration between Public Health England’s National Cancer Intelligence Network and the Cambridge Centre for Health Services Research of the University of Cambridge. GL was supported by a post-doctoral fellowship by the National Institute for Health Research (PDF-2011-04-047) to the end of 2014 and by a Cancer Research UK Clinician Scientist Fellowship award (A18180) from 2015.This is the final version of the article. It first appeared from NPG via http://dx.doi.org/10.1038/bjc.2015.5

The influence of patient case mix on public health area statistics for cancer stage at diagnosis: a cross-sectional study

This is the final version. Available on open access from OUP via the DOI in this recordBACKGROUND: statistics comparing the stage at diagnosis of geographically defined populations of cancer patients are increasingly used in public reporting to monitor geographical inequalities but may be confounded by patient case mix. We explore the impact of case-mix adjustment on a publicly reported measure of early stage at diagnosis in England. METHODS: We analyzed data used for publicly reported statistics about the stage of patients diagnosed with 1 of 11 solid tumours in 2015 in England, including information on cancer site (bladder, breast, colon, rectum, kidney, lung, melanoma, non-Hodgkin lymphoma, ovarian, prostate, endometrial), age, gender, income deprivation and population-based commissioning organization. We investigated how cancer site and other patient characteristics influence organizational comparisons and attainment of early-stage targets (≥60% of all cases diagnosed in TNM stages I-II). RESULTS: Adjusting for patient case mix reduced between-organization variance by more than 50%, resulting in appreciable discordance in organizational ranks (Kendall's tau = 0.53), with 18% (37/207) of organizations being reclassified as meeting/failing the early-stage target due to case mix. CONCLUSION: Summary statistics on stage of cancer diagnosis for geographical populations currently used as public health surveillance tools to monitor organizational inequalities need to account for patient sociodemographic characteristics and cancer site case mix.Cancer Research U

Cancer-specific variation in emergency presentation by sex, age and deprivation across 27 common and rarer cancers

This is the final version. Available on open access from Springer nature via the DOI in this recordBACKGROUND: Although overall sociodemographic and cancer site variation in the risk of cancer diagnosis through emergency presentation has been previously described, relatively little is known about how this risk may vary differentially by sex, age and deprivation group between patients with a given cancer. METHODS: Data from the Routes to Diagnosis project on 749,645 patients (2006-2010) with any of 27 cancers that can occur in either sex were analysed. Crude proportions and crude and adjusted odds ratios were calculated for emergency presentation, and interactions between sex, age and deprivation with cancer were examined. RESULTS: The overall proportion of patients diagnosed through emergency presentation varied greatly by cancer. Compared with men, women were at greater risk for emergency presentation for bladder, brain, rectal, liver, stomach, colon and lung cancer (e.g., bladder cancer-specific odds ratio for women vs men, 1.50; 95% CI 1.39-1.60), whereas the opposite was true for oral/oropharyngeal cancer, lymphomas and melanoma (e.g., oropharyngeal cancer-specific odds ratio for women vs men, 0.49; 95% CI 0.32-0.73). Similarly, younger patients were at higher risk for emergency presentation for acute leukaemia, colon, stomach and oesophageal cancer (e.g., colon cancer-specific odds ratio in 35-44- vs 65-74-year-olds, 2.01; 95% CI 1.76-2.30) and older patients for laryngeal, melanoma, thyroid, oral and Hodgkin’s lymphoma (e.g., melanoma specific odds ratio in 35-44- vs 65-74-year-olds, 0.20; 95% CI 0.12-0.33). Inequalities in the risk of emergency presentation by deprivation group were greatest for oral/oropharyngeal, anal, laryngeal and small intestine cancers. CONCLUSIONS: Among patients with the same cancer, the risk for emergency presentation varies notably by sex, age and deprivation group. The findings suggest that, beyond tumour biology, diagnosis through an emergency route may be associated both with psychosocial processes, which can delay seeking of medical help, and with difficulties in suspecting the diagnosis of cancer after presentation.National Institute for Health Research (NIHR)Cancer Research U

Cancer diagnoses after emergency GP referral or A&E attendance in England: determinants and time trends in Routes to Diagnosis data, 2006-2015

This is the final version. Available on open access from the Royal College of General Practitioners via the DOI in this recordBACKGROUND: Diagnosis of cancer as an emergency is associated with poor outcomes but has a complex aetiology. Examining determinants and time trends in diagnostic routes can help to appreciate the critical role of general practice over time in diagnostic pathways for patients with cancer. AIM: To examine sociodemographic, cancer site, and temporal associations with type of presentation among patients with cancer diagnosed as emergencies. DESIGN AND SETTING: Analysis of Routes to Diagnosis data, 2006-2015, for patients with cancer in England. METHOD: The authors estimated adjusted proportions of emergency presentation after emergency GP referral (GP-EP) or presentation to accident and emergency (AE-EP), by patient sex, age, deprivation group, and year of diagnosis using multivariable regression. RESULTS: Among 554 621 patients presenting as emergencies, 24% (n = 130 372) presented as GP-EP, 62% as AE-EP (n = 346 192), and 14% (n = 78 057) through Other-EP sub-routes. Patients presenting as emergencies were more likely to have been GP-referred if they lived in less deprived areas or were subsequently diagnosed with pancreatic, gallbladder, or ovarian cancer, or acute leukaemia. During the study period the proportion and number of GP-EPs nearly halved (31%, n = 17 364, in 2006; 17%, n = 9155 in 2015), while that of AE-EP increased (55%, n = 31 049 to 68%, n = 36 868). CONCLUSION: Patients presenting as emergencies with cancers characterised by symptoms/signs tolerable by patients but appropriately alarming to doctors (for example, pancreatic cancer manifesting as painless jaundice) are over-represented among cases whose emergency presentation involved GP referral. Reductions in diagnoses of cancer through an emergency presentation likely reflect both the continually increasing use of 2-week-wait GP referrals during the study period and reductions in emergency GP referrals.Cancer Research U

Population trends in emergency cancer diagnoses: The role of changing patient case-mix.

BACKGROUND: Diagnosis of cancer through an emergency presentation is associated with worse clinical and patient experience outcomes. The proportion of patients with cancer who are diagnosed through emergency presentations has consequently been introduced as a routine cancer surveillance measure in England. Welcome reductions in this metric have been reported over more than a decade but whether reductions reflect true changes in how patients are diagnosed rather than the changing case-mix of incident cohorts in unknown. METHODS: We analysed 'Routes to Diagnosis' data on cancer patients (2006-2015) and used logistic regression modelling to determine the contribution of changes in four case-mix variables (sex, age, deprivation, cancer site) to time-trends in emergency presentations. RESULTS: Between 2006 and 2015 there was an absolute 4.7 percentage point reduction in emergency presentations (23.8%-19.2%). Changing distributions of the four case-mix variables explained 19.0% of this reduction, leaving 81.0% unexplained. Changes in cancer site case-mix alone explained 16.0% of the total reduction. CONCLUSION: Changes in case-mix (particularly that of cancer sites) account for about a fifth of the overall reduction in emergency presentations. This would support the use of adjustment/standardisation of reported statistics to support their interpretation and help appreciate the influence of case-mix, particularly regarding cancer sites with changing incidence. However, most of the reduction in emergency presentations remains unaccounted for, and likely reflects genuine changes during the study period in how patients were being diagnosed

Are inequalities in cancer diagnosis through emergency presentation narrowing, widening or remaining unchanged? Longitudinal analysis of English population-based data 2006-2013

This is the final version. Available on open access from BMJ Publishing Group via the DOI in this recordThis project involves data derived from patient-level information collected by the NHS, as part of the care and support of patients with cancer. The data are collated, maintained and quality assured by the National Cancer Registration and Analysis Service, which is part of Public Health England (PHE). Access to the data was facilitated by the PHE Office for Data Release (release ODR_2014_252).Background Diagnosis of cancer through emergency presentation is associated with poorer prognosis. While reductions in emergency presentations have been described, whether known sociodemographic inequalities are changing is uncertain. Methods We analysed 'Routes to Diagnosis' data on patients aged ≥25 years diagnosed in England during 2006-2013 with any of 33 common or rarer cancers. Using binary logistic regression we determined time-Trends in diagnosis through emergency presentation by age, deprivation and cancer site. Results Overall adjusted proportions of emergency presentations decreased during the study period (2006: 23%, 2013: 20%). Substantial baseline (2006) inequalities in emergency presentation risk by age and deprivation remained largely unchanged. There was evidence (p<0.05) of reductions in the risk of emergency presentations for most (28/33) cancer sites, without apparent associations between the size of reduction and baseline risk (p=0.26). If there had been modest reductions in age inequalities (ie, patients in each age group acquiring the same percentage of emergency presentations as the adjacent group with lower risk), in the last study year we could have expected around 11 000 fewer diagnoses through emergency presentation (ie, a nationwide percentage of 16% rather than the observed 20%). For similarly modest reductions in deprivation inequalities, we could have expected around 3000 fewer (ie, 19%). Conclusion The proportion of cancer diagnoses through emergency presentation is decreasing but age and deprivation inequalities prevail, indicating untapped opportunities for further improvements by reducing these inequalities. The observed reductions in proportions across nearly all cancer sites are likely to reflect both earlier help-seeking and improvements in diagnostic healthcare pathways, across both easier-To-suspect and harder-To-suspect cancers.Cancer Research U

Emergency diagnosis of cancer and previous general practice consultations: insights from linked patient survey data

BACKGROUND: Emergency diagnosis of cancer is common and aetiologically complex. The proportion of emergency presenters who have consulted previously with relevant symptoms is uncertain. AIM: To examine how many patients with cancer, who were diagnosed as emergencies, have had previous primary care consultations with relevant symptoms; and among those, to examine how many had multiple consultations. DESIGN AND SETTING: Secondary analysis of patient survey data from the 2010 English Cancer Patient Experience Survey (CPES), previously linked to population-based data on diagnostic route. METHOD: For emergency presenters with 18 different cancers, associations were examined for two outcomes (prior GP consultation status; and 'three or more consultations' among prior consultees) using logistic regression. RESULTS: Among 4647 emergency presenters, 1349 (29%) reported no prior consultations, being more common in males (32% versus 25% in females, P<0.001), older (44% in ≥85 versus 30% in 65-74-year-olds, P<0.001), and the most deprived (35% versus 25% least deprived, P = 0.001) patients; and highest/lowest for patients with brain cancer (46%) and mesothelioma (13%), respectively (P<0.001 for overall variation by cancer site). Among 3298 emergency presenters with prior consultations, 1356 (41%) had three or more consultations, which were more likely in females (P<0.001), younger (P<0.001), and non-white patients (P = 0.017) and those with multiple myeloma, and least likely for patients with leukaemia (P<0.001). CONCLUSION: Contrary to suggestions that emergency presentations represent missed diagnoses, about one-third of emergency presenters (particularly those in older and more deprived groups) have no prior GP consultations. Furthermore, only about one-third report multiple (three or more) consultations, which are more likely in 'harder-to-suspect' groups.Georgios Lyratzopoulos is supported by a Cancer Research UK Advanced Clinician Scientist Fellowship, award Number A18180

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

This is the final version. Available from Elsevier via the DOI in this record. BACKGROUND: Early 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. METHODS: In 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. FINDINGS: We 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. INTERPRETATION: Despite 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. FUNDING: UK Department of Health's Policy Research Unit in Cancer Awareness, Screening and Early Diagnosis; and Cancer Research UK.Cancer Research UKUK Department of Health’s Policy Research Unit in Cancer Awareness, Screening and Early Diagnosi

Diagnosis of cancer as an emergency: a critical review of current evidence

Many patients with cancer are diagnosed through an emergency presentation, which is associated with inferior clinical and patient-reported outcomes compared with those of patients who are diagnosed electively or through screening. Reducing the proportion of patients with cancer who are diagnosed as emergencies is, therefore, desirable; however, the optimal means of achieving this aim are uncertain owing to the involvement of different tumour, patient and health-care factors, often in combination. Most relevant evidence relates to patients with colorectal or lung cancer in a few economically developed countries, and defines emergency presentations contextually (that is, whether patients presented to emergency health-care services and/or received emergency treatment shortly before their diagnosis) as opposed to clinically (whether patients presented with life-threatening manifestations of their cancer). Consistent inequalities in the risk of emergency presentations by patient characteristics and cancer type have been described, but limited evidence is available on whether, and how, such presentations can be prevented. Evidence on patients' symptoms and health-care use before presentation as an emergency is sparse. In this Review, we describe the extent, causes and implications of a diagnosis of cancer following an emergency presentation, and provide recommendations for public health and health-care interventions, and research efforts aimed at addressing this under-researched aspect of cancer diagnosis

Emergency diagnosis of cancer and previous general practice consultations: Insights from linked patient survey data

This is the final published version. Available from the Royal College of General Practitioners via the DOI in this record.Background: Emergency diagnosis of cancer is common and aetiologically complex. The proportion of emergency presenters who have consulted previously with relevant symptoms is uncertain. Aim To examine how many patients with cancer, who were diagnosed as emergencies, have had previous primary care consultations with relevant symptoms; and among those, to examine how many had multiple consultations. Design and setting Secondary analysis of patient survey data from the 2010 English Cancer Patient Experience Survey (CPES), previously linked to populationbased data on diagnostic route. Method For emergency presenters with 18 different cancers, associations were examined for two outcomes (prior GP consultation status; and 'three or more consultations' among prior consultees) using logistic regression. Results Among 4647 emergency presenters, 1349 (29%) reported no prior consultations, being more common in males (32% versus 25% in females, P<0.001), older (44% in ≥85 versus 30% in 65-74-year-olds, P<0.001), and the most deprived (35% versus 25% least deprived, P = 0.001) patients; and highest/lowest for patients with brain cancer (46%) and mesothelioma (13%), respectively (P<0.001 for overall variation by cancer site). Among 3298 emergency presenters with prior consultations, 1356 (41%) had three or more consultations, which were more likely in females (P<0.001), younger (P<0.001), and non-white patients (P = 0.017) and those with multiple myeloma, and least likely for patients with leukaemia (P<0.001). Conclusion Contrary to suggestions that emergency presentations represent missed diagnoses, about one-third of emergency presenters (particularly those in older and more deprived groups) have no prior GP consultations. Furthermore, only about one-third report multiple (three or more) consultations, which are more likely in 'harderto- suspect' groups.Cancer Research U