Emergency department involvement in the diagnosis of cancer among older adults: a SEER-Medicare study.

BACKGROUND: Internationally, 20% to 50% of cancer is diagnosed through emergency presentation, which is associated with lower survival, poor patient experience, and socioeconomic disparities, but population-based evidence about emergency diagnosis in the United States is limited. We estimated emergency department (ED) involvement in the diagnosis of cancer in a nationally representative population of older US adults, and its association with sociodemographic, clinical, and tumor characteristics. METHODS: We analyzed Surveillance, Epidemiology, and End Results Program-Medicare data for Medicare beneficiaries (≥66 years old) with a diagnosis of female breast, colorectal, lung, and prostate cancers (2008-2017), defining their earliest cancer-related claim as their index date, and patients who visited the ED 0 to 30 days before their index date to have "ED involvement" in their diagnosis, with stratification as 0 to 7 or 8 to 30 days. We estimated covariate-adjusted associations of patient age, sex, race and ethnicity, marital status, comorbidity score, tumor stage, year of diagnosis, rurality, and census-tract poverty with ED involvement using modified Poisson regression. RESULTS: Among 614 748 patients, 23% had ED involvement, with 18% visiting the ED in the 0 to 7 days before their index date. This rate varied greatly by tumor site, with breast cancer at 8%, colorectal cancer at 39%, lung cancer at 40%, and prostate cancer at 7%. In adjusted models, older age, female sex, non-Hispanic Black and Native Hawaiian or Other Pacific Islander race, being unmarried, recent year of diagnosis, later-stage disease, comorbidities, and poverty were associated with ED involvement. CONCLUSIONS: The ED may be involved in the initial identification of cancer for 1 in 5 patients. Earlier, system-level identification of cancer in non-ED settings should be prioritized, especially among underserved populations.

What can hospital emergency admissions prior to cancer diagnosis tell us about socio-economic inequalities in cancer diagnosis? Evidence from population-based data in England.

BACKGROUND: More deprived cancer patients are at higher risk of Emergency Presentation (EP) with most studies pointing to lower symptom awareness and increased comorbidities to explain those patterns. With the example of colon cancer, we examine patterns of hospital emergency admissions (HEAs) history in the most and least deprived patients as a potential precursor of EP. METHODS: We analysed the rates of hospital admissions and their admission codes (retrieved from Hospital Episode Statistics) in the two years preceding cancer diagnosis by sex, deprivation and route to diagnosis (EP, non-EP). To select the conditions (grouped admission codes) that best predict emergency admission, we adapted the purposeful variable selection to mixed-effects logistic regression. RESULTS: Colon cancer patients diagnosed through EP had the highest number of HEAs than all the other routes to diagnosis, especially in the last 7 months before diagnosis. Most deprived patients had an overall higher rate and higher probability of HEA but fewer conditions associated with it. CONCLUSIONS: Our findings point to higher use of emergency services for non-specific symptoms and conditions in the most deprived patients, preceding colon cancer diagnosis. Health system barriers may be a shared factor of socio-economic inequalities in EP and HEAs.

Guideline concordance for timely chest imaging after new presentations of dyspnoea or haemoptysis in primary care: a retrospective cohort study.

BACKGROUND: Guidelines recommend urgent chest X-ray for newly presenting dyspnoea or haemoptysis but there is little evidence about their implementation. METHODS: We analysed linked primary care and hospital imaging data for patients aged 30+ years newly presenting with dyspnoea or haemoptysis in primary care during April 2012 to March 2017. We examined guideline-concordant management, defined as General Practitioner-ordered chest X-ray/CT carried out within 2 weeks of symptomatic presentation, and variation by sociodemographic characteristic and relevant medical history using logistic regression. Additionally, among patients diagnosed with cancer we described time to diagnosis, diagnostic route and stage at diagnosis by guideline-concordant status. RESULTS: In total, 22 560/162 161 (13.9%) patients with dyspnoea and 4022/8120 (49.5%) patients with haemoptysis received guideline-concordant imaging within the recommended 2-week period. Patients with recent chest imaging pre-presentation were much less likely to receive imaging (adjusted OR 0.16, 95% CI 0.14-0.18 for dyspnoea, and adjusted OR 0.09, 95% CI 0.06-0.11 for haemoptysis). History of chronic obstructive pulmonary disease/asthma was also associated with lower odds of guideline concordance (dyspnoea: OR 0.234, 95% CI 0.225-0.242 and haemoptysis: 0.88, 0.79-0.97). Guideline-concordant imaging was lower among dyspnoea presenters with prior heart failure; current or ex-smokers; and those in more socioeconomically disadvantaged groups.The likelihood of lung cancer diagnosis within 12 months was greater among the guideline-concordant imaging group (dyspnoea: 1.1% vs 0.6%; haemoptysis: 3.5% vs 2.7%). CONCLUSION: The likelihood of receiving urgent imaging concords with the risk of subsequent cancer diagnosis. Nevertheless, large proportions of dyspnoea and haemoptysis presenters do not receive prompt chest imaging despite being eligible, indicating opportunities for earlier lung cancer diagnosis.

Concordance of Hospital Ranks and Category Ratings Using the Current Technical Specification of US Hospital Star Ratings and Reasonable Alternative Specifications.

Importance: The Centers for Medicare & Medicaid Services (CMS) Hospital Compare star ratings are widely used summaries of hospital quality that can influence patient choice and organizational reputation. Objective: To identify the changes in hospital ratings and rankings associated with alternative methodological choices in the calculation of the 2021 CMS Hospital Compare star ratings. Design Setting and Participants: This cross-sectional study used publicly available 2021 Hospital Compare data for 3339 US hospitals from the October 2020 data release. Change in apparent hospital performance was assessed, arising when plausible alternatives to current methods are used for calculating star ratings in relation to individual measure standardization, domain derivation, and domain weighting. Three example changes were examined in detail, with more comprehensive changes considered using Monte Carlo simulation. Changes in centile of hospital ranks and in star rating overall were examined, as well as separately in CMS peer groupings defined by the number of reported quality domains. Main Outcomes and Measures: Proportion of hospitals receiving a different star rating under the alternative technical specifications than under the current (2021) CMS approach and mean absolute change in centile rank of hospitals under alternative technical specifications compared with the current (2021) CMS approach. Results: A total of 3339 US hospitals were included in the analysis. Of the specific changes to current specifications considered, the alternative method of standardization was associated with the most substantial changes, with 55.4% (95% CI, 53.7%-57.1%) of hospitals having their star rating reclassified. The change in domain weights was associated with the smallest differences, but even that resulted in reclassification of the star rating in approximately 1 in 4 (24.5%; 95% CI, 23.0%-26.0%) hospitals. In the simulation study, which covered a range of possible changes, on average half of hospitals (51.8%; IQR, 44.2%-59.7%) were assigned a different star rating from that produced by the current specification, usually into an adjacent star category. Conclusions and Relevance: In this cross-sectional study of data on US hospitals, CMS Hospital Compare star ratings were found to be highly sensitive to how performance ratings are calculated, demonstrating the need for transparent justification of the technical approaches used in calculating composite performance ratings.

Assessing Ethnic Inequalities in Diagnostic Interval of Common Cancers: A Population-Based UK Cohort Study.

BACKGROUND: This study investigated ethnic differences in diagnostic interval (DI)-the period between initial primary care presentation and diagnosis. METHODS: We analysed the primary care-linked data of patients who reported features of seven cancers (breast, lung, prostate, colorectal, oesophagogastric, myeloma, and ovarian) one year before diagnosis. Accelerated failure time (AFT) models investigated the association between DI and ethnicity, adjusting for age, sex, deprivation, and morbidity. RESULTS: Of 126,627 eligible participants, 92.1% were White, 1.99% Black, 1.71% Asian, 1.83% Mixed, and 2.36% were of Other ethnic backgrounds. Considering all cancer sites combined, the median (interquartile range) DI was 55 (20-175) days, longest in lung [127, (42-265) days], and shortest in breast cancer [13 (13, 8-18) days]. DI for the Black and Asian groups was 10% (AFT ratio, 95%CI 1.10, 1.05-1.14) and 16% (1.16, 1.10-1.22), respectively, longer than for the White group. Site-specific analyses revealed evidence of longer DI in Asian and Black patients with prostate, colorectal, and oesophagogastric cancer, plus Black patients with breast cancer and myeloma, and the Mixed group with lung cancer compared with White patients. DI was shorter for the Other group with lung, prostate, myeloma, and oesophagogastric cancer than the White group. CONCLUSION: We found limited and inconsistent evidence of ethnic differences in DI among patients who reported cancer features in primary care before diagnosis. Our findings suggest that inequalities in diagnostic intervals, where present, are unlikely to be the sole explanation for ethnic variations in cancer outcomes.

Inflammatory marker testing in primary care in the year before Hodgkin lymphoma diagnosis: a UK population-based case-control study in patients aged ≤50 years.

BACKGROUND: Proinflammatory conditions are associated with increased risk of Hodgkin lymphoma, although the neoplastic process per se often induces an inflammatory response. AIM: To examine pre-diagnostic inflammatory marker test use to identify changes that may define a 'diagnostic window' for potential earlier diagnosis. DESIGN AND SETTING: This was a matched case-control study in UK primary care using Clinical Practice Research Datalink data (2002-2016). METHOD: Primary care inflammatory marker test use and related findings were analysed in 839 Hodgkin lymphoma patients and 5035 controls in the year pre-diagnosis. Poisson regression models were used to calculate monthly testing rates to examine changes over time in test use. Longitudinal trends in test results and the presence/absence of 'red-flag' symptoms were examined. RESULTS: In patients with Hodgkin lymphoma, 70.8% (594/839) had an inflammatory marker test in the year pre-diagnosis versus 16.2% (816/5035) of controls (odds ratio 13.7, 95% CI = 11.4 to 16.5, P<0.001). The rate of inflammatory marker testing and mean levels of certain inflammatory marker results increased progressively during the year pre-diagnosis in Hodgkin lymphoma patients while remaining stable in controls. Among patients with Hodgkin lymphoma with a pre-diagnostic test, two-thirds (69.5%, 413/594) had an abnormal result and, among these, 42.6% (176/413) had no other 'red-flag' presenting symptom/sign. CONCLUSION: Increases in inflammatory marker requests and abnormal results occur in many patients with Hodgkin lymphoma several months pre-diagnosis, suggesting this period should be excluded in aetiological studies examining inflammation in Hodgkin lymphoma development, and that a diagnostic time window of appreciable length exists in many patients with Hodgkin lymphoma, many of whom have no other red-flag features.

Ethnic inequalities in routes to diagnosis of cancer: a population-based UK cohort study.

BACKGROUND: UK Asian and Black ethnic groups have poorer outcomes for some cancers and are less likely to report a positive care experience than their White counterparts. This study investigated ethnic differences in the route to diagnosis (RTD) to identify areas in patients' cancer journeys where inequalities lie, and targeted intervention might have optimum impact. METHODS: We analysed data of 243,825 patients with 10 cancers (2006-2016) from the RTD project linked to primary care data. Crude and adjusted proportions of patients diagnosed via six routes (emergency, elective GP referral, two-week wait (2WW), screen-detected, hospital, and Other routes) were calculated by ethnicity. Adjusted odds ratios (including two-way interactions between cancer and age, sex, IMD, and ethnicity) determined cancer-specific differences in RTD by ethnicity. RESULTS: Across the 10 cancers studied, most patients were diagnosed via 2WW (36.4%), elective GP referral (23.2%), emergency (18.2%), hospital routes (10.3%), and screening (8.61%). Patients of Other ethnic group had the highest proportion of diagnosis via the emergency route, followed by White patients. Asian and Black group were more likely to be GP-referred, with the Black and Mixed groups also more likely to follow the 2WW route. However, there were notable cancer-specific differences in the RTD by ethnicity. CONCLUSION: Our findings suggest that, where inequalities exist, the adverse cancer outcomes among Asian and Black patients are unlikely to be arising solely from a poorer diagnostic process.

Deconstructing, Addressing, and Eliminating Racial and Ethnic Inequities in Prostate Cancer Care.

CONTEXT: Men of African ancestry have demonstrated markedly higher rates of prostate cancer mortality than men of other races and ethnicities around the world. In fact, the highest rates of prostate cancer mortality worldwide are found in the Caribbean and Sub-Saharan West Africa, and among men of African descent in the USA. Addressing this inequity in prostate cancer care and outcomes requires a focused research approach that creates durable solutions to address the structural, social, environmental, and health factors that create racial disparities in care and outcomes. OBJECTIVE: To introduce a conceptual model for evaluating racial inequities in prostate cancer care to facilitate the development of translational research studies and interventions. EVIDENCE ACQUISITION: A collaborative review of literature relevant to racial inequities in prostate cancer care and outcomes was performed. Existing literature was used to highlight various components of the conceptual model to inform future research and interventions toward equitable care and outcomes. EVIDENCE SYNTHESIS: Racial inequities in prostate cancer outcomes are driven by a series of structural and social determinants of health that impact exposures, mediators, and outcomes. Social determinants of equity, such as laws/policies, economic systems, and structural racism, affect the inequitable access to environmental and neighborhood exposures, in addition to health care access. Although the incidence disparity remains problematic, various studies have demonstrated parity in outcomes when social and health factors, such as access to equitable care, are normalized. Few studies have tested interventions to reduce inequities in prostate cancer among Black men. CONCLUSIONS: Worldwide, men of African ancestry demonstrate worse outcomes in prostate cancer, a phenomenon driven largely by social factors that inform biologic, environmental, and health care risks. A conceptual model was presented that organizes the many factors that influence prostate cancer incidence and mortality. Within that framework, we must understand the current state of inequities in clinical prostate cancer practice, the optimal state of what equitable practice would be, and how achieving equity in prostate cancer care balances costs, benefits, and harms. More robust characterization of the sources of prostate cancer inequities should inform testing of ambitious and innovative interventions as we work toward equity in care and outcomes. PATIENT SUMMARY: Men of African ancestry demonstrate the highest rates of prostate cancer mortality, which may be reduced through social interventions. We present a framework for formalizing the identification of the drivers of prostate cancer inequities to facilitate the development of interventions and trials to eradicate them.

Sociodemographic inequalities in patients' experiences of primary care: an analysis of the General Practice Patient Survey in England between 2011 and 2017.

OBJECTIVE: Younger people, minority ethnic groups, sexual minorities and people of lower socioeconomic status report poorer experiences of primary care. In light of NHS ambitions to reduce unwarranted variations in care, we aimed to investigate whether inequalities in patient experience of primary care changed between 2011 and 2017, using data from the General Practice Patient Survey in England. METHODS: We considered inequalities in relation to age, sex, deprivation, ethnicity, sexual orientation and geographical region across five dimensions of patient experience: overall experience, doctor communication, nurse communication, access and continuity of care. We used linear regression to explore whether the magnitude of inequalities changed between 2011 and 2017, using mixed models to assess changes within practices and models without accounting for practice to assess national trends. RESULTS: We included 5,241,408 responses over 11 survey waves from 2011-2017. There was evidence that inequalities changed over time (p < 0.05 for 27/30 models), but the direction and magnitude of changes varied. Changes in gaps in experience ranged from a 1.6 percentage point increase for experience of access among sexual minorities, to a 5.6 percentage point decrease for continuity, where experience worsened for older ages. Inequalities in access in relation to socio-economic status remained reasonably stable for individuals attending the same GP practice; nationally inequalities in access increased 2.1 percentage points (p < 0.0001) between respondents living in more/less deprived areas, suggesting access is declining fastest in practices in more deprived areas. CONCLUSIONS: There have been few substantial changes in inequalities in patient experience of primary care between 2011 and 2017.

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

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.

Development of an intervention to expedite cancer diagnosis through primary care: a protocol.

BACKGROUND: GPs can play an important role in achieving earlier cancer diagnosis to improve patient outcomes, for example through prompt use of the urgent suspected cancer referral pathway. Barriers to early diagnosis include individual practitioner variation in knowledge, attitudes, beliefs, professional expectations, and norms. AIM: This programme of work (Wales Interventions and Cancer Knowledge about Early Diagnosis [WICKED]) will develop a behaviour change intervention to expedite diagnosis through primary care and contribute to improved cancer outcomes. DESIGN & SETTING: Non-experimental mixed-method study with GPs and primary care practice teams from Wales. METHOD: Four work packages will inform the development of the behaviour change intervention. Work package 1 will identify relevant evidence-based interventions (systematic review of reviews) and will determine why interventions do or do not work, for whom, and in what circumstances (realist review). Work package 2 will assess cancer knowledge, attitudes, and behaviour of GPs, as well as primary care teams' perspectives on cancer referral and investigation (GP survey, discrete choice experiment [DCE], interviews, and focus groups). Work package 3 will synthesise findings from earlier work packages using the behaviour change wheel as an overarching theoretical framework to guide intervention development. Work package 4 will test the feasibility and acceptability of the intervention, and determine methods for measuring costs and effects of subsequent behaviour change in a randomised feasibility trial. RESULTS: The findings will inform the design of a future effectiveness trial, with concurrent economic evaluation, aimed at earlier diagnosis. CONCLUSION: This comprehensive, evidence-based programme will develop a complex GP behaviour change intervention to expedite the diagnosis of symptomatic cancer, and may be applicable to countries with similar healthcare systems.

Persistent inequalities in unplanned hospitalisation among colon cancer patients across critical phases of their care pathway, England, 2011-13.

BACKGROUND: Reducing hospital emergency admissions is a key target for all modern health systems. METHODS: We analysed colon cancer patients diagnosed in 2011-13 in England. We screened their individual Hospital Episode Statistics records in the 90 days pre-diagnosis, the 90 days post-diagnosis, and the 90 days pre-death (in the year following diagnosis), for the occurrence of hospital emergency admissions (HEAs). RESULTS: Between a quarter and two thirds of patients experience HEA in the three 90-day periods examined: pre-diagnosis, post-diagnosis and before death. Patients with tumour stage I-III from more deprived backgrounds had higher proportions of HEAs than less deprived patients during all studied periods. This remains even after adjusting for differing distributions of risk factors such as age, sex, comorbidity and stage at diagnosis. CONCLUSIONS: Although in some cases HEAs might be unavoidable or even appropriate, the proportion of HEAs varies by socioeconomic status, even after controlling for the usual patient factors, suggestive of remediable causes of excess emergency healthcare utilisation in patients belonging to higher deprivation groups. Future inquiries should address the potential role of clinical complications, sub-optimal healthcare administration, premature discharge or a lack of social support as potential explanations for these patterns of inequality.

Missing data and chance variation in public reporting of cancer stage at diagnosis: Cross-sectional analysis of population-based data in England.

BACKGROUND: The percentage of cancer patients diagnosed at an early stage is reported publicly for geographically-defined populations corresponding to healthcare commissioning organisations in England, and linked to pay-for-performance targets. Given that stage is incompletely recorded, we investigated the extent to which this indicator reflects underlying organisational differences rather than differences in stage completeness and chance variation. METHODS: We used population-based data on patients diagnosed with one of ten cancer sites in 2013 (bladder, breast, colorectal, endometrial, lung, ovarian, prostate, renal, NHL, and melanoma). We assessed the degree of bias in CCG (Clinical Commissioning Group) indicators introduced by missing-is-late and complete-case specifications compared with an imputed 'gold standard'. We estimated the Spearman-Brown (organisation-level) reliability of the complete-case specification. We assessed probable misclassification rates against current pay-for-performance targets. RESULTS: Under the missing-is-late approach, bias in estimated CCG percentage of tumours diagnosed at an early stage ranged from -2 to -30 percentage points, while bias under the complete-case approach ranged from -2 to +7 percentage points. Using an annual reporting period, indicators based on the least biased complete-case approach would have poor reliability, misclassifying 27/209 (13%) CCGs against a pay-for-performance target in current use; only half (53%) of CCGs apparently exceeding the target would be correctly classified in terms of their underlying performance. CONCLUSIONS: Current public reporting schemes for cancer stage at diagnosis in England should use a complete-case specification (i.e. the number of staged cases forming the denominator) and be based on three-year reporting periods. Early stage indicators for the studied geographies should not be used in pay-for-performance schemes.

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.

Educational differences in likelihood of attributing breast symptoms to cancer: a vignette-based study.

BACKGROUND: Stage at diagnosis of breast cancer varies by socio-economic status (SES), with lower SES associated with poorer survival. We investigated associations between SES (indexed by education), and the likelihood of attributing breast symptoms to breast cancer. METHOD: We conducted an online survey with 961 women (47-92 years) with variable educational levels. Two vignettes depicted familiar and unfamiliar breast changes (axillary lump and nipple rash). Without making breast cancer explicit, women were asked 'What do you think this […..] could be?' After the attribution question, women were asked to indicate their level of agreement with a cancer avoidance statement ('I would not want to know if I have breast cancer'). RESULTS: Women were more likely to mention cancer as a possible cause of an axillary lump (64%) compared with nipple rash (30%). In multivariable analysis, low and mid education were independently associated with being less likely to attribute a nipple rash to cancer (OR 0.51, 0.36-0.73 and OR 0.55, 0.40-0.77, respectively). For axillary lump, low education was associated with lower likelihood of mentioning cancer as a possible cause (OR 0.58, 0.41-0.83). Although cancer avoidance was also associated with lower education, the association between education and lower likelihood of making a cancer attribution was independent. CONCLUSION: Lower education was associated with lower likelihood of making cancer attributions for both symptoms, also after adjustment for cancer avoidance. Lower likelihood of considering cancer may delay symptomatic presentation and contribute to educational differences in stage at diagnosis. Copyright © 2016 John Wiley & Sons, Ltd.

Pre-referral GP consultations in patients subsequently diagnosed with rarer cancers: a study of patient-reported data.

BACKGROUND: Some patients with cancer experience multiple pre-diagnostic consultations in primary care, leading to longer time intervals to specialist investigations and diagnosis. Patients with rarer cancers are thought to be at higher risk of such events, but concrete evidence of this is lacking. AIM: To examine the frequency and predictors of repeat consultations with GPs in patients with rarer cancers. DESIGN AND SETTING: Patient-reported data on pre-referral consultations from three English national surveys of patients with cancer (2010, 2013, and 2014), pooled to maximise the sample size of rarer cancers. METHOD: The authors examined the frequency and crude and adjusted odds ratios for ≥3 (versus 1-2) pre-referral consultations by age, sex, ethnicity, level of deprivation, and cancer diagnosis (38 diagnosis groups, including 12 rarer cancers without prior relevant evidence). RESULTS: Among 7838 patients with 12 rarer cancers, crude proportions of patients with ≥3 pre-referral consultations ranged from >30.0% to 60.0% for patients with small intestine, bone sarcoma, liver, gallbladder, cancer of unknown primary, soft-tissue sarcoma, and ureteric cancer. The range was 15.0-30.0% for patients with oropharyngeal, anal, parotid, penile, and oral cancer. The overall proportion of responders with any cancer who had ≥3 consultations was 23.4%. Multivariable logistic regression indicated concordant patterns, with strong evidence for variation between rarer cancers (P <0.001). CONCLUSION: Patients with rarer cancers experience pre-referral consultations at frequencies suggestive of middle-to-high diagnostic difficulty. The findings can guide the development of new diagnostic interventions and 'safety-netting' approaches for symptomatic presentations encountered in patients with rarer cancers.

The expanding role of primary care in cancer control.

The nature of cancer control is changing, with an increasing emphasis, fuelled by public and political demand, on prevention, early diagnosis, and patient experience during and after treatment. At the same time, primary care is increasingly promoted, by governments and health funders worldwide, as the preferred setting for most health care for reasons of increasing need, to stabilise health-care costs, and to accommodate patient preference for care close to home. It is timely, then, to consider how this expanding role for primary care can work for cancer control, which has long been dominated by highly technical interventions centred on treatment, and in which the contribution of primary care has been largely perceived as marginal. In this Commission, expert opinion from primary care and public health professionals with academic and clinical cancer expertise­from epidemiologists, psychologists, policy makers, and cancer specialists­has contributed to a detailed consideration of the evidence for cancer control provided in primary care and community care settings. Ranging from primary prevention to end-of-life care, the scope for new models of care is explored, and the actions needed to effect change are outlined. The strengths of primary care­its continuous, coordinated, and comprehensive care for individuals and families­are particularly evident in prevention and diagnosis, in shared follow-up and survivorship care, and in end-of-life care. A strong theme of integration of care runs throughout, and its elements (clinical, vertical, and functional) and the tools needed for integrated working are described in detail. All of this change, as it evolves, will need to be underpinned by new research and by continuing and shared multiprofessional development.

The impact of age at diagnosis on socioeconomic inequalities in adult cancer survival in England.

BACKGROUND: Understanding the age at which persistent socioeconomic inequalities in cancer survival become apparent may help motivate and support targeting of cancer site-specific interventions, and tailoring guidelines to patients at higher risk. PATIENTS AND METHODS: We analysed data on more than 40,000 patients diagnosed in England with one of three common cancers in men and women, breast, colon and lung, 2001-2005 with follow-up to the end of 2011. We estimated net survival for each of the five deprivation categories (affluent, 2, 3, 4, deprived), cancer site, sex and age group (15-44, 45-54, 55-64, and 65-74 and 75-99 years). RESULTS: The magnitude and pattern of the age specific socioeconomic inequalities in survival was different for breast, colon and lung. For breast cancer the deprivation gap in 1-year survival widened with increasing age at diagnosis, whereas the opposite was true for lung cancer, with colon cancer having an intermediate pattern. The 'deprivation gap' in 1-year breast cancer survival widened steadily from -0.8% for women diagnosed at 15-44 years to -4.8% for women diagnosed at 75-99 years, and was the widest for women diagnosed at 65-74 years for 5- and 10-year survival. For colon cancer in men, the gap was widest in patients diagnosed aged 55-64 for 1-, 5- and 10-year survival. For lung cancer, the 'deprivation gap' in survival in patients diagnoses aged 15-44 years was more than 10% for 1-year survival in men and for 1- and 5-year survival in women. CONCLUSION: Our findings suggest that reduction of socioeconomic inequalities in survival will require updating of current guidelines to ensure the availability of optimal treatment and appropriate management of lung cancer patients in all age groups and older patients in deprived groups with breast or colon cancer.

Sexual minorities in England have poorer health and worse health care experiences: a national survey.

BACKGROUND: The health and healthcare of sexual minorities have recently been identified as priorities for health research and policy. OBJECTIVE: To compare the health and healthcare experiences of sexual minorities with heterosexual people of the same gender, adjusting for age, race/ethnicity, and socioeconomic status. DESIGN: Multivariate analyses of observational data from the 2009/2010 English General Practice Patient Survey. PARTICIPANTS: The survey was mailed to 5.56 million randomly sampled adults registered with a National Health Service general practice (representing 99 % of England's adult population). In all, 2,169,718 people responded (39 % response rate), including 27,497 people who described themselves as gay, lesbian, or bisexual. MAIN MEASURES: Two measures of health status (fair/poor overall self-rated health and self-reported presence of a longstanding psychological condition) and four measures of poor patient experiences (no trust or confidence in the doctor, poor/very poor doctor communication, poor/very poor nurse communication, fairly/very dissatisfied with care overall). KEY RESULTS: Sexual minorities were two to three times more likely to report having a longstanding psychological or emotional problem than heterosexual counterparts (age-adjusted for 5.2 % heterosexual, 10.9 % gay, 15.0 % bisexual for men; 6.0 % heterosexual, 12.3 % lesbian and 18.8 % bisexual for women; p < 0.001 for each). Sexual minorities were also more likely to report fair/poor health (adjusted 19.6 % heterosexual, 21.8 % gay, 26.4 % bisexual for men; 20.5 % heterosexual, 24.9 % lesbian and 31.6 % bisexual for women; p < 0.001 for each). Adjusted for sociodemographic characteristics and health status, sexual minorities were about one and one-half times more likely than heterosexual people to report unfavorable experiences with each of four aspects of primary care. Little of the overall disparity reflected concentration of sexual minorities in low-performing practices. CONCLUSIONS: Sexual minorities suffer both poorer health and worse healthcare experiences. Efforts should be made to recognize the needs and improve the experiences of sexual minorities. Examining patient experience disparities by sexual orientation can inform such efforts.