Non-specific symptoms-based pathways for diagnosing less common cancers in primary care: a service evaluation.

BACKGROUND: Although less common cancers account for almost half of all cancer diagnoses in England, their relative scarcity and complex presentation, often with non-specific symptoms, means that patients often experience multiple primary care consultations, long times to diagnosis, and poor clinical outcomes. An urgent referral pathway for non-specific symptoms, the Multidisciplinary Diagnostic Centre (MDC), may address this problem. AIM: To examine the less common cancers identified during the MDC pilots and consider whether such an approach improves the diagnosis of these cancers. DESIGN AND SETTING: A service evaluation of five MDC pilot projects in England from December 2016 to March 2019. METHOD: Data items were collected by pilot sites in near-real time, based mainly on the English cancer outcomes and services dataset, with additional project-specific items. Simple descriptive and comparative statistics were used, including χ2 tests for proportions and t-tests for means where appropriate. RESULTS: From 5134 referrals, 378 cancers were diagnosed, of which 218 (58%) were less common. More than 30 different less common tumour types were diagnosed in this cohort. Of the MDC patients with less common cancers, 23% (n = 50) had ≥3 GP consultations before referral and, at programme level, a median time of 57 days was recorded from GP urgent referral to treatment for these tumour types. CONCLUSION: A non-specific symptomatic referral route diagnoses a broad range of less common cancers, and can support primary care case management for patients with symptoms of possible cancer that do not qualify for a site-specific urgent referral.

Cross-sectional study using primary care and cancer registration data to investigate patients with cancer presenting with non-specific symptoms.

INTRODUCTION: Patients presenting to primary care with site-specific alarm symptoms can be referred onto urgent suspected cancer pathways, whereas those with non-specific symptoms currently have no dedicated referral routes leading to delays in cancer diagnosis and poorer outcomes. Pilot Multidisciplinary Diagnostic Centres (MDCs) provide a referral route for such patients in England. OBJECTIVES: This work aimed to use linked primary care and cancer registration data to describe diagnostic pathways for patients similar to those being referred into MDCs and compare them to patients presenting with more specific symptoms. METHODS: This cross-sectional study linked primary care data from the National Cancer Diagnosis Audit (NCDA) to national cancer registration and Route to Diagnosis records. Patient symptoms recorded in the NCDA were used to allocate patients to one of two groups - those presenting with symptoms mirroring referral criteria of MDCs (non-specific but concerning symptoms (NSCS)) and those with at least one site-specific alarm symptom (non-NSCS). Descriptive analyses compared the two groups and regression analysis by group investigated associations with long primary care intervals (PCIs). RESULTS: Patients with NSCS were more likely to be diagnosed at later stage (32% stage 4, compared with 21% in non-NSCS) and via an emergency presentation (34% vs 16%). These patients also had more multiple pre-referral general practitioner consultations (59% vs 43%) and primary care-led diagnostics (blood tests: 57% vs 35%). Patients with NSCS had higher odds of having longer PCIs (adjusted OR: 1.24 (1.11 to 1.36)). Patients with lung and urological cancers also had higher odds of longer PCIs overall and in both groups. CONCLUSIONS: Differences in the diagnostic pathway show that patients with symptoms mirroring the MDC referral criteria could benefit from a new referral pathway.

Evaluation of a health service adopting proactive approach to reduce high risk of lung cancer: The Liverpool Healthy Lung Programme.

OBJECTIVES: This Liverpool Healthy Lung Programme is a response to high rates of lung cancer and respiratory diseases locally and aims to diagnose lung cancer at an earlier stage by proactive approach to those at high risk of lung cancer. The objective of this study is to evaluate the programme in terms of its likely effect on mortality from lung cancer and its delivery to deprived populations. METHODS: Persons aged 58-75 years, with a history of smoking or a diagnosis of chronic obstructive pulmonary disease (COPD)2 according to general practice records were invited for lung health check in a community health hub setting. A detailed risk assessment and spirometry were performed in eligible patients. Those with a 5% or greater five-year risk of lung cancer were referred for a low dose CT3 scan. RESULTS: A total of 4 566 subjects attended the appointment for risk assessment and 3 591 (79%) consented to data sharing. More than 80% of the patients were in the most deprived quintile of the index of multiple deprivation. Of those attending, 63% underwent spirometry and 43% were recommended for a CT scan. A total of 25 cancers were diagnosed, of which 16 (64%) were stage I. Comparison with the national stage distribution implied that the programme was reducing lung cancer mortality by 22%. CONCLUSIONS: Community based proactive approaches to early diagnosis of lung cancer in health deprived regions are likely to be effective in early detection of lung cancer.

Establishing population-based surveillance of diagnostic timeliness using linked cancer registry and administrative data for patients with colorectal and lung cancer.

BACKGROUND: Diagnostic timeliness in cancer patients is important for clinical outcomes and patient satisfaction but, to-date, continuous monitoring of diagnostic intervals in nationwide incident cohorts has been impossible in England. METHODS: We developed a new methodology for measuring the secondary care diagnostic interval (SCDI - first relevant secondary care contact to diagnosis) using linked cancer registration and healthcare utilisation data. Using this method, we subsequently examined diagnostic timeliness in colorectal and lung cancer patients (2014-15) by socio-demographic characteristics, diagnostic route and stage at diagnosis. RESULTS: The approach assigned SCDIs to 94.4% of all incident colorectal cancer cases [median length (90th centile) of 25 (104) days] and 95.3% of lung cancer cases [36 (144) days]. Advanced stage patients had shorter intervals (median, colorectal: stage 1 vs 4 - 34 vs 19 days; lung stage 1&2 vs 3B&4 - 70 vs 27 days). Routinely referred patients had the longest (colorectal: 61, lung: 69 days) and emergency presenters the shortest intervals (colorectal: 3, lung: 14 days). Comorbidities and additional diagnostic tests were also associated with longer intervals. CONCLUSION: This new method can enable repeatable nationwide measurement of cancer diagnostic timeliness in England and identifies actionable variation to inform early diagnosis interventions and target future research.

International Adoption of Children Surviving the Haitian Earthquake.

OBJECTIVE: To evaluate resilience and frequency of behavioral symptoms in Haitian children internationally adopted before and after the earthquake of January 12, 2010. METHODS: We conducted a retrospective quantitative study in 40 Haitian children. Families were also asked to participate in a qualitative study (individual interview at 18-24 months after the earthquake) and to complete State-Trait Anxiety Inventory (STAI) and STAI for children (STAI-C) questionnaires. RESULTS: Demographic and clinical characteristics were similar in the group who experienced the earthquake (n=22) and in the group who did not (n=18). The families of 30 adoptees were interviewed. There was no statistical difference between the two groups for the STAI (P=0.53) and STAI-C (P=0.75) or for the frequency of behavioral problems. Plenary adoption was pronounced for 84.6% and 33.3% of the children adopted in the pre- and post-earthquake group, respectively (P=0.02). Children rarely talked about the experience of the earthquake, which, by contrast, was a stressful experience for the adoptive families. CONCLUSIONS: Haitian children adopted after the earthquake did not express more stress or behavioral problems than those adopted before it. However, the possibility of a resurgence of mental disorders after age 10 should be borne in mind. (Disaster Med Public Health Preparedness. 2018;12:450-454).

Skin diseases in internationally adopted children.

Internationally adopted children often present diseases contracted in the country of origin. Skin diseases are common in new arrivals, and diagnosis may prove challenging for GPs or even dermatologists if they are inexperienced in the extensive geographic and ethnic diversity of international adoptees. To analyse the frequency and characteristics of skin diseases in international adoptees. In total, 142 adoptees were evaluated for a cross-sectional cohort study. The most frequent diseases observed at arrival were dermatological conditions. Of the adoptees, 70% presented at least one skin disease, of which 57.5% were infectious; Tinea capitis being the most frequent (n = 42). The recovery rate of Tinea capitis was 89% (n = 32/36). Ten cases of scabies were diagnosed. Other diseases included viral skin infection (n = 22), with 16 cases of Molluscum contagiosum and bacterial infection. Skin diseases are very common in internationally adopted children. There is a need for close collaboration between dermatologists and paediatricians to diagnose such infections, as well as clear guidelines to treat them.

Ecological gradients driving the distribution of four Ericaceae in boreal Quebec, Canada.

Understory species play a significant role in forest ecosystem dynamics. As such, species of the Ericaceae family have a major effect on the regeneration of tree species in boreal ecosystems. It is thus imperative to understand the ecological gradients controlling their distribution and abundance, so that their impacts can be taken into account in sustainable forest management. Using innovative analytical techniques from landscape ecology, we aimed to position, along ecological gradients, four Ericaceae found in the boreal forest of Quebec (Canada) (Rhododendron groenlandicum, Kalmia angustifolia, Chamaedaphne calyculata, and Vaccinium spp), to regionalize these species into landscape units relevant to forest management, and to estimate the relative importance of several ecological drivers (climate, disturbances, stand attributes, and physical environment) that control the species distribution and abundance. We conducted our study in boreal Quebec, over a study area covering 535,355 km(2). We used data from 15,339 ecological survey plots and forest maps to characterize 1422 ecological districts covering the study region. We evaluated the relative proportion of each ericaceous species and explanatory variables at the district level. Vegetation and explanatory variables matrices were used to conduct redundancy, cluster, and variation partitioning analyses. We observed that ericaceous species are mainly distributed in the western part of the study area and each species has a distinct latitudinal and longitudinal gradient distribution. On the basis of these gradients, we delimited 10 homogeneous landscape units distinct in terms of ericaceous species abundance and environmental drivers. The distribution of the ericaceous species along ecological gradients is closely related to the overlaps between the four sets of explanatory variables considered. We conclude that the studied Ericaceae occupy specific positions along ecological gradients and possess a specific abundance and distribution controlled by the integration of multiple explanatory variables.

Health care support issues for internationally adopted children: a qualitative approach to the needs and expectations of families.

BACKGROUND: Families of internationally adopted children may face specific problems with which general practitioners (GPs) may not be familiar. The aim of the study was to explore problems faced by families before, during and after the arrival of their internationally adopted child and to assess the usefulness of a specific medical structure for internationally adopted children, which could be a resource for the GP. METHODOLOGY/PRINCIPAL FINDINGS: We conducted a qualitative study using individual semistructured guided conversations and interviewed 21 families that had adopted a total of 26 children internationally in the Puy de Dome department, France, in 2003. Quantitative data were used to describe the pathologies diagnosed and the investigations performed.Our study showed that the history of these families, from the start of the adoption project to its achievement, is complex and warrants careful analysis. Health-care providers should not only consider the medical aspects of adoption, but should also be interested in the histories of these families, which may play a role in the forming of attachments between the adoptee and their adoptive parents and prevent further trouble during the development of the child. We also showed that adoptive parents have similar fears or transient difficulties that may be resolved quickly by listening and reassurance. Most such families would support the existence of a specific medical structure for internationally adopted children, which could be a resource for the general practitioner. However, the health-care providers interviewed were divided on the subject and expressed their fear that a special consultation could be stigmatizing to children and families. CONCLUSIONS/SIGNIFICANCE: A specific consultation with well-trained and experienced practitioners acting in close collaboration with GPs and paediatricians may be of help in better understanding and supporting adopted children and their families.