Rethinking the logic of early diagnosis in cancer.

To reduce morbidity and mortality of cancer, more countries have implemented strategies to detect cancer, based on the logic of 'the sooner the better'. Time is thereby an essential component in how cancer research, policies, and prevention are practiced today. Where the logic of early diagnosis benefits some, the logic also produces harms. In this article, we use a cross-disciplinary case-study design to discuss how different notions of time and linearity are essential in today's research ontology of cancer, describe the individual and societal consequences of such ontology, and invite a rethinking of time in cancer. Drawing on theoretical concepts of time together with cancer epidemiological, historical and ethnographical data, we analyse how the logic of early diagnosis has been established as a stable concept. Although evidence supporting the logic points in different directions, the message 'the sooner the better' is currently not being challenged by research, policy or society. This at least partly, can be explained by a linear perception of time and societal traces of neoliberalism and acceleration in our society together with cancer still being a somewhat enigmatic disease that requires acute action. To support a sustainable healthcare sector, we argue there is a need to nuance the logic of early diagnosis. Continuing the linear perception of symptoms and cancer, risks doing more harm than good by making more people patients unnecessarily and by spending health resources on those with the least need.

Diagnostic flow for all patients referred with non-specific symptoms of cancer to a diagnostic centre in Denmark: A descriptive study.

BACKGROUND: Since 2012, Cancer Patient Pathways for Non-specific Symptoms and Signs of Cancer (NSSC-CPP) have been implemented in Scandinavia and UK. OBJECTIVES: This study aimed to describe the diagnostic flow for all patients referred from 1 January to 30 June 2020 to the NSSC-CPP in the Diagnostic Centre in Farsø (DC-F), Denmark. METHODS: During the study period, we prospectively recorded information on the diagnostic flow, including: pathway trajectory, symptoms and findings leading to referral, diagnostic procedures and diagnoses at the end of DC Farsø work-up and within 6-months for all patients referred to the NSSC-CPP in DC Farsø using electronic patient files and the Danish National Patient Registry (DNPR). RESULTS: Of the 314 referrals to DC Farsø, 227 had diagnostic work-up in DC Farsø, the remaining were redirected to other CPPs (n = 11), outpatient clinics (n = 45) or redirected to general practice (n = 25). Of total referrals, 25 (8%) received a malignant diagnosis, 20 (6%) a non-malignant but clinically relevant diagnosis with initiation of treatment, 16 (5%) a non-malignant diagnosis but no treatment needed and in 253 (81%) referrals no severe new condition was diagnosed. Two (1%) additional malignancies were diagnosed within a 6-month follow-up period. CONCLUSION: By tracking all patients referred to the NSSC-CPP in DC Farsø, including those redirected, this is the first study to describe the diagnostic flow for all patients referred to a diagnostic centre in Denmark. This knowledge is important for further organisation and planning of the NSSC-CPP.

Eight percent of NSSC-CPP referrals yielded cancer diagnoses, with two additional cancers diagnosed in a 6-month follow-up.Over one-fourth of referrals to NSSC-CPP were redirected to other departments or general practitioners.This study outlines the diagnostic flow for all NSSC-CPP-referred patients, offering unique insights crucial for comparing European diagnostic practices.

Qualitative exploration of the perceptions of exercise in patients with cancer initiated during chemotherapy: a meta-synthesis.

OBJECTIVE: To synthesise qualitative literature on (1) the perceptions of patients with cancer of participating in an exercise intervention while undergoing chemotherapy and (2) to inform and guide professionals in oncology and haematology practice. DESIGN: A qualitative meta-synthesis based on Noblit and Hare's seven-step meta-ethnography. DATA SOURCES: Six electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, EMBASE, PubMed, SCI-Expanded-SSCI and Scopus (final search June 2022) were used to identify qualitative literature containing individual or focus group interviews. The transparency of reporting for each study was assessed using the Consolidated criteria for Reporting Qualitative research checklist. RESULTS: The search identified 5002 articles, 107 of which were selected for full-text review. Seventeen articles from five countries with patients undergoing chemotherapy during exercise interventions were included. Eleven articles were included in the meta-synthesis, which comprised 193 patients with various cancer diagnoses, disease stages, sexes and ages. Four main themes were identified: chemotherapy overpowers the body; exercise in battle with side effects; a break from gloomy thoughts; and a question of survivorship. CONCLUSIONS AND IMPLICATIONS: The meta-synthesis emphasised that patients with cancer undergoing chemotherapy and simultaneously participating in exercise interventions may experience momentary relief from overwhelming side effects, even though full bodily recovery may be perceived as a distant prospect. The synthesis offers a sparse empirical basis for gaining insight into what patients experience existentially following exercise interventions. It is up to patients to independently apply the transfer value of exercise to their own existential circumstances.

Questioning 'Informed Choice' in Medical Screening: The Role of Neoliberal Rhetoric, Culture, and Social Context.

Participation in medical screening programs is presented as a voluntary decision that should be based on an informed choice. An informed choice is often emphasized to rely on three assumptions: (1) the decision-maker has available information about the benefits and harms, (2) the decision-maker can understand and interpret this information, and (3) the decision-maker can relate this information to personal values and preferences. In this article, we empirically challenge the concept of informed choice in the context of medical screening. We use document analysis to analyze and build upon findings and interpretations from previously published articles on participation in screening. We find that citizens do not receive neutral or balanced information about benefits and harms, yet are exposed to manipulative framing effects. The citizens have high expectations about the benefits of screening, and therefore experience cognitive strains when informed about the harm. We demonstrate that decisions about screening participation are informed by neoliberal arguments of personal responsibility and cultural healthism, and thus cannot be regarded as decisions based on individual values and preferences independently of context. We argue that the concept of informed choice serves as a power technology for people to govern themselves and can be considered an implicit verification of biopower.

Colon cancer diagnosed in patients with non-specific symptoms - comparisons between diagnostic paradigms.

Background In Denmark, the Cancer Patient Pathway for Non-Specific Signs and Symptoms (NSSC-CPP) has been implemented with variations: in some areas, general practitioners (GPs) do the initial diagnostic work-up (GP paradigm); in other areas, patients are referred directly to the hospital (hospital paradigm). There is no evidence to suggest the most beneficial organisation. Therefore, this study aims to compare the occurrence of colon cancer and the risk of non-localised cancer stage between the GP and hospital paradigms.Material and Methods In this registry-based case-control study, we applied multivariable binary logistic regression models to estimate the odds ratios (OR) of colon cancer and non-localised stage associated with the GP paradigm and hospital paradigm. All cases and controls were assigned to a paradigm based on their diagnostic activity (CT scan or CPP) six months before the index date. As not all CT scans in the control group were part of the cancer work-up as a sensitivity analysis, we investigated the impact of varying the fraction of these, which were randomly removed using a bootstrap approach for inference.Results The GP paradigm was more likely to result in a cancer diagnosis than the hospital paradigm; ORs ranged from 1.91-3.15 considering different fractions of CT scans as part of cancer work-up. No difference was found in the cancer stage between the two paradigms; ORs ranged from 1.08-1.10 and were not statistically significant.Conclusion Patients in the GP paradigm were diagnosed with colon cancer more often, but we cannot conclude that the distribution of respectively localised or non-localised extent of disease is different from that of patients in the hospital paradigm.

Luckily-I am not the worrying kind: Experiences of patients in the Danish cancer patient pathway for non-specific symptoms and signs of cancer.

In Denmark, due to the implementation of the Non-specific Symptoms and Signs of Cancer-Cancer Patient Pathway (NSSC-CPP), more people with symptoms such as fatigue and weight loss are informed that their symptoms might indicate cancer and they are referred to the pathway. But what do patients in the NSSC-CPP experience, in particular, with respect to being in an affective state of anticipation of a cancer diagnosis? We conducted participant observation and semi-structured interviews with patients to investigate their experience of the NSSC-CPP with a specific focus on their perception of symptoms and their thoughts on worrying about cancer. We found that the phrase 'worried about cancer' was not recognised by the participants, but worry was visible in their increased healthcare use and their interpretation of bodily sensations. Our study indicates the need to explore the impact of anticipation and potential cancer worries in participants' everyday lives, as this context mediates their moral roles and responsibilities and restructures their social lives, while keeping uncertainty and probabilities on the table.

Use and diagnostic outcomes of cancer patient pathways in Denmark - is the place of initial diagnostic work-up an important factor?

INTRODUCTION: The Cancer Patient Pathway for Non-specific Symptoms and Signs of Cancer (NSSC-CPP) has been implemented in Denmark with regional and intra-regional differences. In some places, the initial diagnostic work-up (often including a CT scan) is performed by general practitioners (GPs) and in others by hospitals. Variations may influence the use of Organ Specific Cancer Patient Pathways (OS-CPPs) and prognostic outcomes for the patients. Therefore, the aims were: 1) To analyse how a CT scan referred from GP or hospital is followed by OS-CPPs and NSSC-CPPs at the national and regional level, and 2) To analyse, nationally and regionally, the diagnostic outcomes of persons referred to CT scan by either GP or hospital six months after and mortality one year after CT scan. METHODS: A nationwide population-based study including individuals with a first CT scan in 2013-2016, either referred from GP or hospital. RESULTS: Overall, individuals with a CT scan referred from GPs were more likely to start a NSSC-CPP or an OS-CPP than individuals with a CT scan referred by hospitals. Across the five Regions in Denmark, CT scans referred by GPs were associated with reduced odds of total mortality in all regions; (North, OR=0.78 [0.73 0.83], Central, OR=0.92 [0.87 0.96], South, OR=0.85 [0.81 0.89], Capital, OR=0.96 [0.91 1.00] and Zealand, OR=0.85 [0.79 0.90]) and increased odds of cancer-specific mortality in four regions, ORs ranging from 1.15-1.51 with no difference in Region North (1.00 [0.91 1.10]). CONCLUSION: No obvious association between more CT scans and CPPs and reduced diagnoses and mortality was observed. The different diagnostic models might not explain the prognostic outcomes, but the different use of CT scans in, and between Regions play a large role in the differences in incidence and mortality.

Psychosocial consequences of screening-detected abdominal aortic aneurisms: a cross-sectional study.

OBJECTIVE: In Sweden, an abdominal aortic aneurysm (AAA) screening programme was gradually implemented from 2009 to reduce the incidence of rupture and thereby mortality. AAA screening introduces a variety of unintended, but generally unavoidable, harms, e.g. stress and worry. Such psychosocial consequences have previously only been investigated with generic measures. Therefore, the aim of this study was to describe and compare the psychosocial consequences in men with a screening detected AAA to men with a normal screening result after they participated in the Swedish national AAA-screening programme using a validated psychometric instrument. MATERIAL AND METHODS: This study was a cross-sectional survey. Data were originally collected to validate the COS-AAA and has previously been published in details. The Consequences of Screening in Abdominal Aortic Aneurysm (COS-AAA) questionnaire was sent to 250 men with a screening detected AAA and 500 with a normal screening result who were randomly selected from a Swedish population-based screening register. RESULTS: In total, 158 (63%) men with a screening detected AAA and 275 (55%) men with a normal screening result completed the COS-AAA. We found that men with a screening detected AAA reported negative psychosocial consequences to a greater extent in 10 of 13 COS-AAA Part 1 scales, all statistically significant except three (behaviour, sleep and negative experiences from examination). For COS-AAA Part 2, there was a statistically significant difference between groups in four of five scales. CONCLUSIONS: Men diagnosed with a screening detected AAA, reported more negative psychosocial consequences compared to men with a normal result. Screening for abdominal aorta aneurism (AAA) introduces intended benefits and unintended harms. Adequate measures are necessary to determine the balance between them.Key points:This study applied a condition-specific questionnaire with high content validity and adequate psychometric properties to measure psychosocial consequences in men participating in AAA screening.We found that men with a screening detected AAA reported more negative psychosocial consequences than men with a normal aorta size.The risk of negative psychosocial consequences is important to include in the decision making on whether to participate in screening or not.

Re: Hofmann et al. Overdiagnosis, one concept, three perspectives, and a model.

It is with great interest we have read the article "Overdiagnosis: one concept, three perspectives, and a model" by Hofmann and colleagues. We share the authors' ambition of understanding what overdiagnosis is and what it isn't. In our research, we define overdiagnosis on the basis of two interrelated phenomena: overdetection and overdefinition. Overdetection is the labelling of a person with a disease or abnormal condition, that would not have caused the person harm, e.g., symptoms or death, if left undiscovered. Overdefinition is the creation of new diagnoses by overmedicalising ordinary life experiences or expanding existing diagnoses by lowering thresholds or widening diagnostic criteria, without evidence of improved outcomes. These phenomena have different causes and thereby often different drivers. However, they have one important consequence in common: people are turned into patients unnecessarily, i.e., overdiagnosed. On a personal level, overdiagnosis cause various types of harms, including physical, psychological, social and financial harm. On a societal level, overdiagnosis may also cause harm to public health, cause resource waste, and cultural changes with overmedicalisation of normal life events. By definition, none of the aforementioned phenomena lead to any clinical benefit. Therefore, we disagree with Hofmann and colleagues' definition of overdiagnosis as diagnoses that "…on balance, do more harm than good.". We argue that introducing balance and benefits to the definition of overdiagnosis complicates the concept unnecessarily and cause problems operationalising overdiagnosis.

Psychosocial consequences of a three-month follow-up after receiving an abnormal lung cancer CT-screening result: A longitudinal survey.

BACKGROUND: Participation in lung cancer CT-screening can be associated with a need for follow-up procedures. The screening and waiting for test results introduce the risk of experiencing psychosocial consequences. Therefore, the aims of this study were: 1) To investigate if the psychosocial consequences changed from before an annual screening round to before a three-month follow-up CT-scan in participants with a positive screening result. 2) To investigate potential differences in psychosocial consequences between false positives (FP) and true positives (TP). FP were defined as those where cancer was not confirmed in the follow-up CT-scan and TP where it was. MATERIALS AND METHODS: This longitudinal study was based on data from the Danish Lung Cancer Screening Trial (DLCST). The Consequences of Screening - Lung cancer (COS-LC) questionnaire was used to measure psychosocial consequences among 130 participants who all received an abnormal CT-screening result at their annual screening round. Eligible participants completed the COS-LC before their annual CT-screening and before the three-month follow-up. RESULTS: We found a statistically significant increase in negative psychosocial consequences between the annual lung cancer CT-screening and the three-month follow-up CT-scan in four of nine psychosocial scales; Sense of dejection, Self-blame, Focus on airway symptoms and Harm of smoking. Furthermore, an increase, however not statistically significant, was identified in all remaining scales, except for the scale Stigmatisation which was slightly decreased. We found no evidence of an association between psychosocial consequences and diagnostic groups, FP and TP. CONCLUSIONS: An increase in negative psychosocial consequences was observed between the annual lung cancer CT-screening and the three-month follow-up CT-scan. Since we found no statistically significant difference between the diagnostic groups, the increase in negative psychosocial consequences is interpreted as a nocebo effect of living three months in uncertainty not knowing if one's positive CT-screening result was true or false.

Non-specific symptoms and signs of cancer: different organisations of a cancer patient pathway in Denmark.

OBJECTIVE: We aimed to investigate the Non-specific Symptoms and Signs of Cancer-Cancer Patient Pathway (NSSC-CPP) in order to describe organisational and clinical practice similarities and differences in the diagnostic work-up of suspected cancer in Denmark. MATERIAL AND METHODS: A questionnaire on the organisation and practice pertaining to the NSSC-CPP was completed by all 21 diagnostic units in the five healthcare regions in Denmark. RESULTS: The questionnaire responses revealed regional and intraregional differences in the organisation and clinical practice of the NSSC-CPP. CT scan was the most often used imaging in the NSSC-CPP but there was no consensus whether the CT scan should be ordered and evaluated by general practitioners (GPs) or by the diagnostic units. Two regions were consistent but had different modalities regarding referrals from GPs. Three regions had intra-regional differences. The units reported on different types and frequency of forum for patient plan discussion and how to end a NSSC-CPP. CONCLUSION: The NSSC-CPP is implemented with great regional and intra-regional differences in Denmark. GPs face different requirements when referring to the NSSC-CPP, which indicates that the division of role and responsibility between GPs and the diagnostic units is not well defined.KEY POINTSIn Denmark, the cancer patient pathway for non-specific symptoms and signs of cancer (NSSC-CPP) has been implemented with variations, but little is known about these different modalities. This study showed that both at a regional and an intra-regional level:•General practitioners meet different implementation of national guidelines in the diagnostic units when referring to the NSSCP-CPP•The suitable patient group for the NSSC-CPP is not well defined•Quality criteria are needed to monitor, evaluate and improve the diagnostic work-up for patients with non-specific symptoms and signs of cancer.

Barriers and enablers of COPD telerehabilitation - a frontline staff perspective.

Background: Telerehabilitation (TR) aimed at patients with COPD has shown promising effects on symptoms, physical function, and quality of life, but little research has been conducted to understand the impact of implementation on frontline health professionals. Therefore, the aim of this study was to examine the barriers and enablers of health professionals to online exercise-based TR in patients with COPD, to support a successful implementation process. Methods: Semistructured individual and focus group interviews were conducted with 25 health professionals working with conventional COPD rehabilitation or TR. Interviews were audio-taped and transcribed verbatim. Investigator triangulation was applied during data generation. The Theoretical Domains Framework directed the interview guide and was used as a coding framework in the analysis. Results: We identified six predominant domains essential in understanding the enablers and barriers of TR from a staff perspective: 1) skills, 2) professional role and identity, 3) beliefs about capabilities, 4) beliefs about consequences, 5) environmental context and resources, and 6) social influences. We found that health professionals held both enablers and barriers important for the implementation process of TR. TR introduces new work tasks and new ways for the health professionals to communicate and exercise with the patients, which influence their professional role and self-perceived capability. Conclusion: Specific attention toward involvement of the health professionals in the decision process combined with sufficient education and skill training is highly essential to support a successful implementation of TR in clinical practice.