Understanding Pathways to the Diagnosis of Thyroid Cancer: Are There Ways We Can Reduce Over-Diagnosis?

BACKGROUND: The incidence of thyroid cancer has rapidly increased, and ecological evidence suggests this is due in some part to over-diagnosis. Understanding pathways to diagnosis could help determine whether unnecessary diagnosis can be avoided. METHODS: A population-based sample (n = 1007) of thyroid cancer patients diagnosed between July 2013 and August 2016 was recruited from Queensland, Australia (response rate 67%). Information from structured telephone interviews was used to describe diagnostic pathways for thyroid cancer, to investigate factors associated with diagnostic pathways, and to assess the most prevalent modes of diagnoses by which the lowest-risk, potentially over-diagnosed thyroid cancers (intrathyroidal microcarcinomas) are detected. RESULTS: Only 38% of participants presented with symptoms potentially related to thyroid cancer. Older age at diagnosis was associated with a lower prevalence of symptomatic diagnosis (prevalence ratio [PR] = 0.46 [confidence interval (CI) 0.31-0.68] for 70-79 vs. <30 years), as was frequent medical contact, while living in rural/regional areas was associated with a higher prevalence of symptomatic diagnosis (PR = 1.17 [CI 1.00-1.37] for rural/regional areas vs. major cities). Symptomatic diagnosis also occurred more for those whose tumors had adverse histopathological features (larger size, lymph node involvement, lymphovascular invasion). The likelihood of diagnosis of intrathyroidal microcarcinomas was greatest for those having surgical resection or monitoring for benign thyroid disease (PR = 3.87 [CI 2.81-5.32] and PR = 2.21 [CI 1.53-3.18], respectively). CONCLUSIONS: A minority of newly detected thyroid cancer cases were diagnosed because of symptoms. Access to medical care and factors related to cancer aggressiveness were associated with how diagnoses occurred. The likelihood of diagnosing the lowest-risk thyroid cancers was higher in situations related to management of other thyroid conditions. Adherence to thyroid management guidelines could reduce some thyroid cancer over-diagnosis, but ultimately better diagnostic tools are needed to differentiate between indolent cancers and those of clinical significance.

Outcomes following colorectal cancer surgery: Results from a population-based study in Queensland, Australia, using quality indicators.

RATIONALE, AIMS AND OBJECTIVES: Colorectal cancer (CRC) is one of the most common cancers diagnosed worldwide, and rates are continuing to rise. Surgery is the primary treatment for CRC, and our aim was to examine clinical outcomes following major resection using a series of established quality indicators and to identify factors associated with poor clinical outcomes. METHOD: This population-based retrospective study included 4321 patients with diagnosed with CRC in 2012 and 2014 in Queensland, Australia, who underwent a major resection. Primary outcomes included in-hospital mortality, 30-day unplanned readmission, extended hospital stay (>21 days), and 30- and 90-day mortality. Multivariable logistic regression modelling was conducted to establish factors independently associated with each outcome of interest. RESULTS: Overall, in-hospital mortality was 1.5%, 3.0% had an unplanned readmission, 8% had an extended hospital stay, and 30- and 90-day postoperative mortality was 1.6% and 3.1%, respectively. After adjustment, we found that factors such as older age, presence of comorbidities, emergency admission, and stoma formation were significantly associated with poorer outcomes with these findings being consistent across each of the outcomes of interest. In addition to these factors, the risk of 90-day mortality was significantly elevated for patients with advanced stage disease (OR = 1.95, CI 1.35-2.82). Sex, primary site, hospital volume, residential location, nor socioeconomic status was found to be associated with any of the outcomes of interest. CONCLUSION: Overall, the risk of poorer clinical outcomes for CRC patients in Queensland, Australia, is low. There is however a subgroup of patients at particularly elevated risk of poorer outcomes following CRC. Strategies to reduce the poorer clinical outcomes this group of patients experience should be explored.

Cost-Effectiveness Analysis of a Skin Awareness Intervention for Early Detection of Skin Cancer Targeting Men Older Than 50 Years.

OBJECTIVES: To assess the cost-effectiveness of an educational intervention encouraging self-skin examinations for early detection of skin cancers among men older than 50 years. METHODS: A lifetime Markov model was constructed to combine data from the Skin Awareness Trial and other published sources. The model incorporated a health system perspective and the cost and health outcomes for melanoma, squamous and basal cell carcinomas, and benign skin lesions. Key model outcomes included Australian costs (2015), quality-adjusted life-years (QALYs), life-years, and counts of skin cancers. Univariate and probabilistic sensitivity analyses were undertaken to address parameter uncertainty. RESULTS: The mean cost of the intervention was A$5,298 compared with A$4,684 for usual care, whereas mean QALYs were 7.58 for the intervention group and 7.77 for the usual care group. The intervention was thus inferior to usual care. When only survival gain is considered, the model predicted the intervention would cost A$1,059 per life-year saved. The likelihood that the intervention was cost-effective up to A$50,000 per QALY gained was 43.9%. The model was stable to most data estimates; nevertheless, it relies on the specificity of clinical diagnosis of skin cancers and is subject to limited health utility data for people with skin lesions. CONCLUSIONS: Although the intervention improved skin checking behaviors and encouraged men to seek medical advice about suspicious lesions, the overall costs and effects from also detecting more squamous and basal cell carcinomas and benign lesions outweighed the positive health gains from detecting more thin melanomas.

Geographical Inequalities in Surgical Treatment for Localized Female Breast Cancer, Queensland, Australia 1997-2011: Improvements over Time but Inequalities Remain.

The uptake of breast conserving surgery (BCS) for early stage breast cancer varies by where women live. We investigate whether these geographical patterns have changed over time using population-based data linkage between cancer registry records and hospital inpatient episodes. The study cohort consisted of 11,631 women aged 20 years and over diagnosed with a single primary invasive localised breast cancer between 1997 and 2011 in Queensland, Australia who underwent either BCS (n = 9223, 79%) or mastectomy (n = 2408, 21%). After adjustment for socio-demographic and clinical factors, compared to women living in very high accessibility areas, women in high (Odds Ratio (OR) 0.58 (95% confidence intervals (CI) 0.49, 0.69)), low (OR 0.47 (0.41, 0.54)) and very low (OR 0.44 (0.34, 0.56)) accessibility areas had lower odds of having BCS, while  the odds for women from middle (OR 0.81 (0.69, 0.94)) and most disadvantaged (OR 0.87 (0.71, 0.98)) areas was significantly lower than women living in affluent areas. The association between accessibility and the type of surgery reduced over time (interaction p = 0.028) but not for area disadvantage (interaction p = 0.209). In making informed decisions about surgical treatment, it is crucial that any geographical-related barriers to implementing their preferred treatment are minimised.

A multilevel investigation of inequalities in clinical and psychosocial outcomes for women after breast cancer.

BACKGROUND: In Australia, breast cancer is the most common cancer affecting Australian women. Inequalities in clinical and psychosocial outcomes have existed for some time, affecting particularly women from rural areas and from areas of disadvantage. We have a limited understanding of how individual and area-level factors are related to each other, and their associations with survival and other clinical and psychosocial outcomes. METHODS/DESIGN: This study will examine associations between breast cancer recurrence, survival and psychosocial outcomes (e.g. distress, unmet supportive care needs, quality of life). The study will use an innovative multilevel approach using area-level factors simultaneously with detailed individual-level factors to assess the relative importance of remoteness, socioeconomic and demographic factors, diagnostic and treatment pathways and processes, and supportive care utilization to clinical and psychosocial outcomes. The study will use telephone and self-administered questionnaires to collect individual-level data from approximately 3, 300 women ascertained from the Queensland Cancer Registry diagnosed with invasive breast cancer residing in 478 Statistical Local Areas Queensland in 2011 and 2012. Area-level data will be sourced from the Australian Bureau of Statistics census data. Geo-coding and spatial technology will be used to calculate road travel distances from patients' residence to diagnostic and treatment centres. Data analysis will include a combination of standard empirical procedures and multilevel modelling. DISCUSSION: The study will address the critical question of: what are the individual- or area-level factors associated with inequalities in outcomes from breast cancer? The findings will provide health care providers and policy makers with targeted information to improve the management of women with breast cancer, and inform the development of strategies to improve psychosocial care for women with breast cancer.

Association between melanoma thickness, clinical skin examination and socioeconomic status: results of a large population-based study.

Survival from melanoma is inversely related to tumour thickness and is less favorable for those in lower socioeconomic (SES) strata. Reasons for this are unclear but may relate to a lower prevalence of skin screening. Our aim was to examine the association between melanoma thickness, individual-level SES and clinical skin examination (CSE) using a population-based case-control study. Cases were Queensland (Australia) residents aged 20-75 years with a histologically confirmed first primary invasive cutaneous melanoma diagnosed between January 2000 and December 2003. Telephone interviews were completed by 3,762 cases (77.7%) and 3,824 (50.4%) controls. Thickness was dichotomized to thin (≤2 mm) and thick (>2 mm). Compared with controls, the risk of thick melanoma was significantly increased among men [relative risk ratio (RRR) = 1.56, 95% CI = 1.22-2.00], older participants (RRR = 1.76, 95% CI = 1.10-2.82), those educated to primary level (RRR = 1.70, 95% CI = 1.08-2.66), not married/living as married (RRR = 1.47, 95% CI = 1.15-1.88), retired (RRR = 1.39, 95% CI = 1.01-1.94) and not having a CSE in past 3 years (RRR = 1.45, 95% CI = 1.12-1.86). There was a significant trend to increasing prevalence of CSE with higher education (p < 0.01) and the benefit of CSE in reducing the risk of thick melanoma was most pronounced among that subgroup. There were no significant associations between cases with thin melanoma and controls. Melanoma thickness at presentation is significantly associated with educational level, other measures of SES and absence of CSE. Public health education efforts should focus on identifying new avenues that specifically target those subgroups of the population who are at increased risk of being diagnosed with thick melanoma.

Diagnosing skin cancer in primary care: how do mainstream general practitioners compare with primary care skin cancer clinic doctors?

OBJECTIVE: To measure and compare the casemix and diagnostic accuracy of excised or biopsied skin lesions managed by mainstream general practitioners and doctors within primary care skin cancer clinics. DESIGN, SETTING AND PARTICIPANTS: Prospective comparative study of 104 GPs and 50 skin cancer clinic doctors in south-eastern Queensland, involving 28 755 patient encounters. The study was conducted in 2005. MAIN OUTCOME MEASURES: Prevalence of each type of skin lesion; sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for the clinical diagnosis against histology; number needed to excise or biopsy (NNE) for a diagnosis of skin cancer. RESULTS: GPs excised or biopsied 3175 skin lesions (mean 2.5/week) including 743 basal cell carcinomas (BCCs) (23.4%), 704 squamous cell carcinomas (SCCs) (22.2%) and 49 melanomas (1.5%). Skin cancer clinic doctors excised or biopsied 7941 skin lesions (mean 34/week), including 2701 BCCs (34.0%), 1274 SCCs (16.0%) and 103 melanomas (1.3%). Overall, sensitivity for diagnosing any skin cancer was similar for skin cancer clinic doctors (0.94) and GPs (0.91), although higher for skin cancer clinic doctors for BCC (0.89 v 0.79; P < 0.01) and melanoma (0.60 v 0.29; P < 0.01). The overall NNE was similar for skin cancer clinic doctors (1.9; 95% CI, 1.8%-2.1%) and GPs (2.1; 95% CI, 1.9%-2.3%). This did not change after adjusting for years of clinical experience. CONCLUSIONS: GPs and skin cancer clinic doctors in Queensland treat large numbers of skin cancers and diagnose these with overall high sensitivity. The two groups diagnosed skin cancer with similar accuracy.

Diagnosis and management costs of suspicious skin lesions from a population-based melanoma screening programme.

BACKGROUND: Recently, massive increases in health-care costs for the diagnosis and management of skin lesions have been observed (2000-05). The aim of this study was to describe the health system costs attributed to the diagnosis and management of suspicious skin lesions detected during a trial of a population melanoma screening programme (1998-2001). SETTING: Queensland, Australia. METHODS: Data from the trial and Medicare Australia were used to categorize and cost all suspicious skin lesions arising from the trial, which included general practitioner consultations, diagnosis/management and pathology. Comparisons were made with other screened and unscreened populations. RESULTS: Overall, 2982 lesions were treated within the trial producing a mean cost of Aus$118 per lesion. Excisions for benign lesions contributed the greatest proportion of total costs (45%). The total cost burden was approximately 10% higher for men than women, and 63% of overall costs were for persons aged >or=50 years. For diagnosis and management procedures, the estimated average cost per 1000 individuals was Aus$23,560 for men aged >or=50 years from the skin cancer screening trial, compared with Aus$26,967 for BreastScreen Australia and Aus$3042 for the National Cervical Screening Program. CONCLUSIONS: The proportion of costs for benign skin lesions and biopsies arising from the screening programme were no higher than in the two-year period outside the trial. While comparisons are difficult, it appears that diagnostic and management costs for skin cancer as a result of screening may be comparable with those for BreastScreen Australia, if screening is targeted at men aged >or=50 years.

Attitudes, knowledge and practice of CRC screening among GPs in Queensland.

BACKGROUND: Colorectal cancer (CRC) is the most common invasive cancer in Australia. Randomised trials have shown that mortality from CRC can be reduced with the use of screening modalities such as faecal occult blood testing (FOBT). This study sought to determine current attitudes, knowledge and practices of general practitioners in relation to CRC screening. METHODS: A cross sectional survey of 1500 GPs in Queensland. RESULTS: Responses were received from 769 (55.6%) GPs. Fifty-three percent of GPs recommended using FOBT for asymptomatic patients over 50 years of age and 18.6% would recommend colonoscopy in such patients. Compared to a previous survey, GPs are now more likely to use FOBT (RR: 2.01, 95% CI: 1.58-2.56). Two-thirds (66.7%) would support a population based screening program using FOBT, an increase of 16% over 3 years. DISCUSSION: Current use of FOBT in asymptomatic patients, support for population based FOBT, and knowledge of the benefits of CRC screening has increased significantly from previous surveys.

Comparability of skin screening histories obtained by telephone interviews and mailed questionnaires: a randomized crossover study.

The comparability of information collected through telephone interviews and information collected through mailed questionnaires has not been well studied. As part of the first phase of a randomized controlled trial of population screening for melanoma in Queensland, Australia, the authors compared histories of skin examination reported in telephone interviews and self-administered mailed questionnaires. A total of 1,270 subjects each completed a telephone interview and a mailed questionnaire 1 month apart in 1999; 564 subjects received the interview first, and 706 received the mailed questionnaire first. Agreement between the two methods was 91.2% and 88.6% for whole-body skin examination by a physician in the last 12 months and the last 3 years, respectively, and 81.9% for whole-body skin self-examination in the last 12 months. Agreement was lower for "any" skin self-examination. Agreement between the two methods was similar regardless of whether the interview or the questionnaire was administered first. Missing data were less frequent for interviews (0.5%) than for mailed questionnaires (3.8%). Costs were estimated at A$9.55 (US$6.21) per completed interview and A$3.01 (US$1.96) per questionnaire. The similarity of results obtained using telephone interviews and mailed questionnaires, coupled with the substantially higher cost of telephone interviews, suggests that self-administered mailed questionnaires are an appropriate method of assessing this health behavior.