Geographical access to GPs and modes of cancer diagnosis in England: a cross-sectional study.

BACKGROUND: Poor geographical access to health services and routes to a cancer diagnosis such as emergency presentations have previously been associated with worse cancer outcomes. However, the extent to which access to GPs determines the route that patients take to obtain a cancer diagnosis is unknown. METHODS: We used a linked dataset of cancer registry and hospital records of patients with a cancer diagnosis between 2006 and 2010 across eight different cancer sites. Primary outcomes were defined as 'desirable routes to diagnosis' [screen-detected and 2-week wait (TWW) referrals] and 'less desirable routes' [emergency presentations and death certificate only (DCO)]. All other routes (GP referral, inpatient elective and other outpatient) were specified as the reference category. Geographical access was measured as travel time in minutes from patients to their GP, and multinomial logistic regression was used to estimate relative risk ratios (RRR). RESULTS: Longer travel was associated with increased risk of diagnosis via emergency and DCO, but decreased risk of diagnosis via screening and TWW. Patients travelling over 30 minutes had the highest risk of a DCO diagnosis, which was statistically significant for breast, colorectal, lung, prostate, stomach and ovarian cancers (compared with patients with travel times ≤10 minutes: RRR 5.89, 7.02, 2.30, 4.75, 10.41; P < 0.01 and 3.51, P < 0.05). DISCUSSION: Poor access to GPs may discourage early engagement with health services, decreasing the likelihood of screening uptake and increasing the likelihood of emergency presentations. Extra effort is needed to promote early diagnosis in more distant patients.

Outcome of elevated CA125 values from primary care following implementation of ovarian cancer guidelines.

Background: Ovarian cancer presents later in the UK compared to economically similar countries. National guidance suggests measuring CA125 in primary care as a means of bringing patients to specialist attention. Aim: To investigate the outcome of CA125 values measured in accordance with this policy. Setting and design: Examination of the laboratory records of female patients from the usual catchment population of one general hospital in whom CA125 was measured from primary care in a calendar year. Methods: Those with values >35 u/ml were identified. Electronic records within the hospital were interrogated to identify what further evaluation had been undertaken whether ovarian or primary peritoneal cancer had been diagnosed or what other pathology was identified. We also reviewed the CA125 measurement history of patients diagnosed over 3 years by any route. Results: One hundred and sixty-four new cases of CA125 ≥35 u/ml were found. Further information was available for 152 of them. Sixteen had ovarian or primary peritoneal cancer and 16 had other cancers. In 50 no cause for the abnormality was found. The remainder had various non-malignant conditions. The specificity for carcinoma of ovary/primary peritoneal carcinoma was 95.4% [95% confidence interval: 94.8-96.0). In a 3-year period, 65 patients were diagnosed with ovarian or primary peritoneal cancer, 5 had values of CA125 between 20 and 35 u/ml shortly before diagnosis. Conclusions: The CA125 level is a useful diagnostic test for ovarian cancer which has been embraced by primary care but higher sensitivity for earlier disease will require strategies to improve the specificity.

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.

Using serum CA125 to assess the activity of potential cytostatic agents in ovarian cancer.

OBJECTIVE: New strategies are required to rapidly identify novel cytostatic agents before embarking on large randomized trials. This study investigates whether a change in rate of rise (slope) of serum CA125 from before to after starting a novel agent could be used to identify cytostatic agents. Tamoxifen was used to validate this hypothesis. METHODS: Asymptomatic patients with relapsed ovarian cancer who had responded to chemotherapy were enrolled and had CA125 measurements taken every 4 weeks, then more frequently when rising. Once levels reached 4 times the upper limit of normal or nadir, they started continuous tamoxifen 20 mg daily, as well as fortnightly CA125 measurements until symptomatic progression. Because of the potentially nonlinear relationship of CA125 over time, it was felt that to enable normal approximations to be utilized a natural logarithmic standard transformation [ln(CA125)] was the most suitable to improve linearity above the common logarithmic transformation to base 10. RESULTS: From 235 recruited patients, 81 started tamoxifen and had at least 4 CA125 measurements taken before and 4 CA125 measurements taken after starting tamoxifen, respectively. The mean regression slopes from using at least 4 1n(CA125) measurements immediately before and after starting tamoxifen were 0·0149 and 0·0093 [ln(CA125)/d], respectively. This difference is statistically significant, P = 0·001. Therefore, in a future trial with a novel agent, at least as effective as tamoxifen, using this effect size, the number of evaluable patients needed, at significance level of 5% and power of 80%, is 56. CONCLUSIONS: Further validation of this methodology is required, but there is potential to use comparison of mean regression slopes of ln(CA125) as an interim analysis measure of efficacy for novel cytostatic agents in relapsed ovarian cancer.

Piloting a novel cancer care pathway: socioeconomic background as a barrier to access.

BACKGROUND: The multidisciplinary diagnostic clinic (MDC) model for 'non-specific' symptoms has been piloted in the UK. We aimed to assess the degree to which the MDC pathway was influenced by socioeconomic factors. METHODS: We collected data for all patients referred to the MDC from 01 January 2017 - 28 March 2019. Indices of multiple deprivation (IMD) scores were matched to patients' postcodes and referring general practitioner (GP) location. Socioeconomic data for MDC patients was compared with all other cancer patients diagnosed in the MDC's base hospital, Airedale General Hospital (AGH), in 2018. Statistical significance was tested using the Mann-Whitney U test and Spearman's rank correlation. RESULTS: No significant difference was found between MDC pathway and the rest of AGH when comparing social deprivation of patients.There was a moderate negative correlation between the IMD associated with the location of GP premises and the number of referrals; practices in more deprived locations referred fewer patients (p≤0.025). CONCLUSION: The MDC pathway referral rate seems to be affected by social deprivation in a similar manner to other cancer diagnosis pathways. Our work highlights the importance of engaging GP practices with socially deprived populations as the MDC programme is rolled out across the UK.

Requests from primary care for chest X-ray and CA125 measurements during the COVID-19 emergency: An observational study.

During the first 3 months of 2020, as the COVID-19 pandemic developed, it was noticed that requests from primary care for investigations were decreasing, including those that form part of the diagnostic process for cancers. We therefore obtained data on the requests from primary care for chest X-rays (CXRs) and CA125 measurement our hospital received in the first half of 2020 and compared them with 2019. The number of CXRs declined by 93% in April 2020 compared with 2019, with the decline being greater for patient living in outlying areas. Requests from the emergency department also declined. Requests for CA125 measurement similarly fell by 77% from all areas. The requests increased in June, CA125 more than CXR. If this phenomenon is widespread it may have an impact on diagnosis of major conditions, particularly cancers and tuberculosis.

Epirubicin and cyclophosphamide, methotrexate, and fluorouracil as adjuvant therapy for early breast cancer.

BACKGROUND: The National Epirubicin Adjuvant Trial (NEAT) and the BR9601 trial examined the efficacy of anthracyclines in the adjuvant treatment of early breast cancer. METHODS: In NEAT, we compared four cycles of epirubicin followed by four cycles of cyclophosphamide, methotrexate, and fluorouracil (CMF) with six cycles of CMF alone. In the BR9601 trial, we compared four cycles of epirubicin followed by four cycles of CMF, with eight cycles of CMF alone every 3 weeks. The primary end points were relapse-free and overall survival. The secondary end points were adverse effects, dose intensity, and quality of life. RESULTS: The two trials included 2391 women with early breast cancer; the median follow-up was 48 months. Relapse-free and overall survival rates were significantly higher in the epirubicin-CMF groups than in the CMF-alone groups (2-year relapse-free survival, 91% vs. 85%; 5-year relapse-free survival, 76% vs. 69%; 2-year overall survival, 95% vs. 92%; 5-year overall survival, 82% vs. 75%; P<0.001 by the log-rank test for all comparisons). Hazard ratios for relapse (or death without relapse) (0.69; 95% confidence interval [CI], 0.58 to 0.82; P<0.001) and death from any cause (0.67; 95% CI, 0.55 to 0.82; P<0.001) favored epirubicin plus CMF over CMF alone. Independent prognostic factors were nodal status, tumor grade, tumor size, and estrogen-receptor status (P<0.001 for all four factors) and the presence or absence of vascular or lymphatic invasion (P=0.01). These factors did not significantly interact with the effect of epirubicin plus CMF. The overall incidence of adverse effects was significantly higher with epirubicin plus CMF than with CMF alone but did not significantly affect the delivered-dose intensity or the quality of life. CONCLUSIONS: Epirubicin plus CMF is superior to CMF alone as adjuvant treatment for early breast cancer. (ClinicalTrials.gov number, NCT00003577 [ClinicalTrials.gov].).

Oral anticancer medicines in acute oncology; recognition by non-specialist clinicians and risk reduction measures.

OBJECTIVE: This study investigated the awareness of non-oncology specialist medical staff about commonly used oral anticancer medicines (OAMs). METHODS: Interviews conducted with a range of non-oncology specialist doctors. RESULTS: The recognition of OAMs was poor by all grades of doctors, with capecitabine being the only drug recognised by more than half the doctors (26 of 40; 65%). Consultant medical staff scored significantly better than most junior grades of staff. CONCLUSIONS: A barrier to safe patient care appears to be the initial identification of OAMs on acute admission. Once a drug had been identified as an OAM, doctors are aware that they should not prescribe it and should contact the acute oncology service for advice. A range of measures has been introduced to improve the identification of OAMs by doctors.

Geographical disparities in access to cancer management and treatment services in England.

This study seeks to examine the extent to which cancer services are geographically located according to cancer incidence, and assess the association with cancer survival. We identified hospital sites serving English PCTs (Primary Care Trusts) with the management and treatment of breast, lung and colorectal cancer. Geographical access was estimated as travel time in minutes from LSOAs (Lower Super Output Areas) to the nearest hospital site and aggregated to PCT level. Correlations between PCT level mean travel times and cancer cases were estimated using Spearman's rank correlation. Associations between PCT level mean travel times and cancer relative survival rates were estimated using linear regression with adjustment for area deprivation and for a PCT level measure of the reported ease of obtaining a doctor's appointment. We found that cancer services tended to be located farther from areas with more cancer cases, and longer average travel times are associated with worse survival after adjustment for age, sex, year and area deprivation. This suggests that geographical access to cancer services remains a concern in England.

A visitor with Munchausen's syndrome.

The arrival on the hospital ward of a person who was fabricating an illness was an unsettling experience for the medical and nursing staff involved. As the patient was expected only to be present for a short time and claimed to have a proven diagnosis, the approach may have been less rigorous than usual. The article describes the experience of three members of staff with a patient who proved to have Munchausen's syndrome, and their reaction to discovering the truth.