The impact of cancer patient pathway on timing of radiotherapy and survival: a cohort study in glioblastoma patients.

PURPOSE: Glioblastoma (GBM) is an aggressive brain tumor in which primary therapy is standardized and consists of surgery, radiotherapy (RT), and chemotherapy. However, the optimal time from surgery to start of RT is unknown. A high-grade glioma cancer patient pathway (CPP) was implemented in Norway in 2015 to avoid non-medical delays and regional disparity, and to optimize information flow to patients. This study investigated how CPP affected time to RT after surgery and overall survival. METHODS: This study included consecutive GBM patients diagnosed in South-Eastern Norway Regional Health Authority from 2006 to 2019 and treated with RT. The pre CPP implementation group constituted patients diagnosed 2006-2014, and the post CPP implementation group constituted patients diagnosed 2016-2019. We evaluated timing of RT and survival in relation to CPP implementation. RESULTS: A total of 1212 patients with GBM were included. CPP implementation was associated with significantly better outcomes (p < 0.001). Median overall survival was 12.9 months. The odds of receiving RT within four weeks after surgery were significantly higher post CPP implementation (p < 0.001). We found no difference in survival dependent on timing of RT below 4, 4-6 or more than 6 weeks (p = 0.349). Prognostic factors for better outcomes in adjusted analyses were female sex (p = 0.005), younger age (p < 0.001), solitary tumors (p = 0.008), gross total resection (p < 0.001), and higher RT dose (p < 0.001). CONCLUSION: CPP implementation significantly reduced time to start of postoperative RT. Survival was significantly longer in the period after the CPP implementation, however, timing of postoperative RT relative to time of surgery did not impact survival.

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.

Age and Referral Route Impact the Access to Diagnosis for Women with Advanced Ovarian Cancer.

Purpose: The majority of women with ovarian cancer are diagnosed in late stages. Most women do have symptoms prior to diagnosis, sometimes several months before the diagnosis. The aim of this study was to evaluate the timeline from the first presentation of symptoms to a physician until there is a reasonable suspicion of cancer, among women diagnosed with advanced stage ovarian cancer. We wanted to investigate which symptoms were the most common and whether there are other factors affecting the time interval before the suspicion of cancer was confirmed. Patients and Methods: This was a retrospective population-based cohort study of women diagnosed with advanced ovarian cancer between January 1, 2017 and December 31, 2019 who were referred to Skane University Hospital Lund, Sweden. Data were collected from electronic medical records at Skane University Hospital. The time interval was recorded as the time from first physician consultation with predefined symptoms to the date when there was a reasonable suspicion of ovarian cancer. Data processing and statistical analysis were performed with the statistical software R. Results: Among the 249 patients included in this study, the median time interval from the first consultation to the reasonable suspicion of cancer was 24 days. The first consultation in specialized care had a 70% decrease in delay compared to primary care. Emergency consultations had a 52.2% decrease in time delay compared to planned consultations. Older age was associated with an increase in the geometric mean by 54.7%, comparing the first to the third quartile. The most common symptom was abdominal pain. Conclusion: The length of time interval from first presentation with symptoms relating to ovarian cancer to reasonable suspicion of cancer was associated with whether the consultation was in primary or specialized care, emergency or planned visit and the patient's age.

Deconstructing (e)health literacy: aspects that promote and inhibit understanding of health information in breast cancer patient pathways.

Purpose Deconstructing current definitions of "health literacy (HL)" and "eHealth literacy (eHL)", into the core notion of "understanding health information (HI)", this study provides insights into what promotes and inhibits the understanding of HI for breast cancer patients during cancer patient pathways (CCP) in Norway. Methods Seven well-educated women were interviewed. Through a stepwise deductive-inductive analysis of the transcribed interviews, the following topics were identified: 1) explanations accompanied by drawings, 2) individualized knowledge-based information, 3) information processing capacity, and 4) ambiguity in medical information. Results The women's understanding of HI increased when spoken communication was accompanied by visual illustrations, which served as roadmaps throughout the CPP. Even if HI should be targeted to the patients' individual needs, some HI can be generalized if it refers to established knowledge about the health phenomena. The women described their changing mental and physical status during the CPP and how these changes influenced their understanding of HI. Conclusion The results challenge the idea that HL and eHL are fixed, stable, personal characteristics. On the contrary, HL/eHL, in this case particularly the understanding of HI, depends on the individual (temporary) physical and cognitive capacity of the patient and adaptation in the institutional and private contexts.

Diagnosing pancreatic cancer in general practice: a cross-sectional study on associations between suspicion of cancer, urgent referral and time to diagnosis.

OBJECTIVE: This study aimed to investigate the first point of contact in patients diagnosed with pancreatic cancer, and to study factors associated with the GP's suspicion of cancer, Cancer Patient Pathway (CPP) referral and long diagnostic interval. DESIGN: Cross-sectional study combining register and survey data. PATIENTS: Patients with incident pancreatic cancer recorded in the Danish National Patient Register (n = 303). MAIN OUTCOME MEASURES: The patient's first point of symptoms presentation, GP's cancer suspicion, CPP referral and diagnostic interval. RESULTS: General practice was the first point of contact for 85.5% of the population. At the first consultation, cancer was suspected in 32.7% and 22.9% were referred to a CPP. The GPs were more likely to suspect cancer or serious illness in patients aged >70 years (prevalence rate ratio (PRR) 1.34, 95% CI 1.09-1.66) and among patients with high comorbidity (PRR 1.23, 95% CI 1.04-1.47). A CPP referral was less likely among patients with low education. The median diagnostic interval was 39 days (interquartile range: 15-72). When the GP initially did not suspect cancer, the likelihood of longer diagnostic interval increased. CONCLUSION: The majority of patients with pancreatic cancer began their diagnostic route in general practice. Diagnosing pancreatic cancer swiftly in general practice was challenging; the GP did often not initially suspect cancer or refer to a CPP and several of the patient characteristics were associated with the GPs initial suspicion of cancer or CPP referral. Thus, there may be room for improvements in the diagnostics of pancreatic cancer in general practice.Key pointsPatients with pancreatic cancer have a poor prognosis, as pancreatic cancer is often diagnosed in late stage.The majority of patients with pancreatic cancer began their diagnostic process in general practice.General practitioners (GPs) suspected cancer at the first consultation in one out of three patients with pancreatic cancer; more often in older and comorbid patients.The GPs suspicion of cancer was associated with urgent referral and shorter time to diagnosis.

Shared decision-making in standardized cancer patient pathways in Norway-Narratives of patient experiences.

BACKGROUND: Cancer patient pathways (CPPs) were implemented in Norway in 2015-2017 to advance cancer diagnostics and treatment initiation. The aim of CPPs is to ensure standardized waiting times, but also to strengthen patient participation and shared decision-making. This study investigates how patients enrolled in a CPP experienced shared decision-making. METHODS: This study comprised of 19 individual semistructured interviews with patients who had been enrolled in a CPP at three hospitals in Norway. Twelve patients had breast cancer, four patients had prostate cancer and three patients had malignant melanoma. We analyzed their experiences using a narrative approach. FINDINGS: This study showed how participating in a standardized CPP provided different possibilities for shared decision-making. The patients' narratives of shared decision-making in CPPs included stories from the three cancer diagnoses through the following themes: (1) The predictable safeness of standardizations, (2) the ambivalence of making decisions and (3) opposing standardizations and pushing for action. CONCLUSION: Standardized CPPs provided patients with predictability and safety. Shared decision-making was possible when the cancer diagnoses supported preference-sensitive treatment options. Balancing standardizations with individualized care is necessary to facilitate patient participation in CPPs, and the possibility of shared decision-making needs to be discussed for each specific CPP. PATIENT OR PUBLIC CONTRIBUTION: A service user representative from the Norwegian Cancer Society participated in designing this study.

Knowledge of and support for cancer patient pathways among general practitioners and other physicians - a study from Sweden.

OBJECTIVE: To investigate the expertise in and support of the implemented new method of cancer patient pathways (CPPs) among general practitioners (GPs) and other working physicians in Sweden. DESIGN: A survey in the form of 10 knowledge-based multiple-choice questions (MCQs) and two general questions about CPPs. SETTING: Physicians from two different regions in Sweden answered the survey between December 2018 and January 2019. SUBJECTS: GPs in primary care compared to other physicians. 155 participants completed the survey and the response rate was 65%. MAIN OUTCOME MEASURES: Physicians' self-estimated knowledge of CPPs in general and opinion of CPPs effect on mortality and morbidity. Their scores on 10 different MCQs. Scores were analysed in subgroups related to the physicians medical specialty and experience. RESULTS: A majority of all physicians (63%) felt that they had insufficient knowledge regarding the procedure of CPPs, and the average score from the MCQs was 3.8 out of 10 correct answers. The results showed that GPs performed significantly better than specialists from other disciplines. CONCLUSIONS: The low percentage of correctly answered MCQs shows that the information about the entry part of CPPs needs to be improved. The study demonstrates a support for the system with CPPs because the physicians believed in its' positive effects on morbidity and mortality, however, it also reveals a lack of self-estimated knowledge about the system with CPPs.Key pointsCancer patient pathways (CPPs) is a newly implemented method in Sweden that aims to equalize cancer care and reduce the time to diagnosis and treatment.The proficiency of when to initiate an investigation according to a specific CPP seems low. General practitioners (GPs) performed significantly better on knowledge-based questions than other specialists did.Physicians rated their knowledge as insufficient regarding the procedure of CPPs.A clear majority of physicians believed that CPPs promotes a lower mortality and morbidity in cancer.

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.

Ovarian cancer stage, variation in transvaginal ultrasound examination rates and the impact of an urgent referral pathway: A national ecological cohort study.

INTRODUCTION: The aim of this study was to determine whether variation in transvaginal ultrasound examination rates in Danish general practice populations is associated with ovarian cancer outcomes, and to explore the impact of the introduction of a cancer patient pathway for ovarian cancer. MATERIAL AND METHODS: We performed a national register-based cohort study of gynecological cancer-free women aged 40 years or above, living in Denmark and listed with a specific general practitioner in 2004-2014. Practice populations were divided into quartiles according to the general practitioners' transvaginal ultrasound propensity in the preceding year. Associations between transvaginal ultrasound rates and ovarian cancer outcomes were analyzed using Poisson and logistic regression. RESULTS: We included 2769 general practices with 1 739 422 listed women, of whom 5325 were diagnosed with ovarian cancer during the study period. Practices varied twofold in transvaginal ultrasound rates before and after the implementation of the cancer patient pathway. Before the cancer patient pathway was introduced, women listed with practices with the highest transvaginal ultrasound rates were diagnosed with earlier stages of ovarian cancer (odds ratio 1.38, 95% confidence interval 1.06 to 1.81) and had a higher proportion of borderline tumors (incidence rate ratio 1.38, 95% confidence interval 1.10 to 1.75) compared with women least exposed to transvaginal ultrasound. After the cancer patient pathway, no significant differences were identified between the groups. CONCLUSIONS: Before the cancer patient pathway, women exposed most to transvaginal ultrasound were significantly more likely to be diagnosed with early stage ovarian cancer compared with those least exposed to transvaginal ultrasound. After the cancer patient pathway was implemented, the difference disappeared. This suggests that increased awareness and access to transvaginal ultrasound is useful for diagnosing early-stage ovarian cancer.

Delay in Treatment After Cancer Diagnosis in Adolescents and Young Adults: Does Facility Transfer Matter?

Background: Timeliness is one of the fundamental yet understudied quality metrics of cancer care. Little is known about cancer treatment delay among adolescent and young adult (AYA) cancer patients. This study assessed cancer treatment delay, with a specific focus on facility transfer and diagnosis/treatment interval. Methods: Based on MultiCare Health System's (MHS's) institutional cancer registry data of AYA patients diagnosed during 2006-2015, this study analyzed patient demographics, insurance, clinical characteristics, and time of diagnosis and treatment initiation. Chi-squared tests, cumulative hazard estimates, and Cox proportional regression were used for univariable analysis. Multivariate regression models were used to test the association between care transfer and days of interval or prolonged delay, controlling for baseline parameters. Results: Of 840 analytic AYA cases identified, 457 (54.5%) were both diagnosed and treated within MHS. A total of 45.5% were either diagnosed or treated elsewhere. Mean and median intervals for treatment initiation were 27.03 (95% CI = 21.94-33.14) and 8.00 days (95% CI = 5.00-11.00), respectively, with significant differences between patients with and without facility transfer. Transfer was significantly correlated with longer length of diagnosis-to-treatment interval. Treatment delay, ≥1 week, was associated with transfer, female sex, older age, no surgery involvement, and more treatment modalities. Treatment delay, ≥4 weeks, was associated with transfer, female sex, no insurance, and no surgery involvement. Conclusion: In a community care setting, the diagnosis-to-treatment interval is significantly longer for transferred AYA cancer patients than for patients without a transfer. Future studies are warranted to explore the prognostic implications and the reasons for delays within specific cancer types.

Surgical breast cancer patient pathway: Experiences of patients and relatives and their unmet needs.

BACKGROUND AND AIM: Breast cancer is the most common cancer disease in women worldwide. In Denmark, the law prescribes cancer patient pathways (CPPs) in general and thus also for breast cancer. Although results from patient satisfaction surveys show overall satisfaction with the pathway, a call for improvement has been voiced for some areas. The aim of this study was to explore patients' and relatives' experiences with the surgical breast CPP and to identify any unmet needs. METHOD: This study was based on focus groups with patients who had surgery for breast cancer, and their relatives. The settings were two Danish surgical breast cancer clinics. FINDINGS: Overall, patients and relatives found the structure of the surgical breast CPP satisfactory. The time in the surgical department was short, and most patients found it difficult to cope with the situation. Empathy and a supportive relationship between patients, relatives and health-care professionals were of great importance. Five key points were identified in which some of the participants had unmet needs. Suggestions for change were related to information, communication, choice of treatment, flexibility in the pathway and easy access to the clinic after surgery. CONCLUSION: Although patients and relatives found the CPP for breast cancer satisfactory and well planned, suggestions for change were made relating to unmet needs with respect to five key points in the pathway. Implementing findings from this study in clinical practice requires co-operation between health-care professionals and support from the leaders of the organization.

Diagnostic property of direct referral from general practitioners to contrast-enhanced thoracoabdominal CT in patients with serious but non-specific symptoms or signs of cancer: a retrospective cohort study on cancer prevalence after 12 months.

OBJECTIVES: To describe the diagnostic properties of thoracoabdominal contrast-enhanced CT (ceCT), when general practitioners (GPs) managed referral to ceCT through the non-specific symptoms or signs of cancer-cancer patient pathway (NSSC-CPP). DESIGN: Retrospective cohort study including patients from a part of Denmark. SETTING: Department of Internal Medicine at a university hospital. PARTICIPANTS: In total, 529 patients underwent ceCT. PRIMARY AND SECONDARY OUTCOMES: Our primary objective was to estimate the negative and positive likelihood ratios for being diagnosed with cancer within 1 year after ceCT. Our secondary outcomes were prevalence and final diagnoses of malignancy (including temporal trends since implementation of NSSC-CPP in 2012), the prevalence of revision of CT scans and referral patterns based on ceCT results. RESULTS: In total, 529 subjects underwent ceCT and malignancy was identified in 104 (19.7%) patients; 101 (97.1%) during initial workup and 3 patients during the subsequent 12 months follow-up.Eleven patients had a false-negative ceCT, and revision classified the ceCT as 'probable/possible malignancy' in eight (73%) patients. The negative predictive value was 98% and positive predictive value 63%. Negative and positive likelihood ratios for malignancy was 0.1 and 7.9, respectively. CONCLUSION: Our study shows that ceCT as part of GP-coordinated workup has a low negative likelihood ratio for identifying malignancy; this is important since identifying patients for further workup is vital.

Patient characteristics and cancer prevalence in the Danish cancer patient pathway for patients with serious non-specific symptoms and signs of cancer-A nationwide, population-based cohort study.

BACKGROUND: A new cancer patient pathway for patients presenting with non-specific signs and symptoms (NSSC-CPP) was implemented nationally in Denmark in 2012. This study aims to describe, on a national level, the characteristics of patients referred to the Danish NSSC-CPP, and to estimate the prevalence and distribution of cancers and other diagnosis in this population. METHODS: A population-based cohort study using the Danish national registries, including all patients who completed a diagnostic course through the NSSC-CPP between 2012 and 2015. Cancer prevalence is presented as the percentage of included patients who were diagnosed with cancer after completing a NSSC-CPP diagnostic course. Associations between patient characteristics and cancer diagnosis were estimated in a multivariate logistic regression model. RESULTS: The mean age of the 23,934 patients included in the analysis was 64.6 years and 47% where male. In total, 11% of all patients received a cancer diagnosis after completing a diagnostic course in the NSSC-CPP; the most common types were breast cancer (18%) hematopoietic and lymphoid tissue cancer (15%), and malignant melanoma (12%). The most common non-cancer diagnosis was non-specific symptoms/observation (54%). Fifty-five patients were diagnosed with cancer within six months following a non-cancer diagnosis in the NSSC-CPP. CONCLUSIONS: The prevalence of cancer in the NSSC-CPP was 11%. The most common cancer diagnosis was breast cancer, hematopoietic and lymphoid cancer and malignant melanoma. A small proportion of patients receiving a non-cancer diagnosis in the NSSC-CPP were diagnosed with cancer in the six months following their NSSC-CPP course.

DaPeCa-2: Implementation of fast-track clinical pathways for penile cancer shortens waiting time and accelerates the diagnostic process--A comparative before-and-after study in a tertiary referral centre in Denmark.

OBJECTIVE: The aim of this study was to examine the feasibility and impact of a fast-track referral pathway on clinical time intervals in penile cancer. MATERIALS AND METHODS: This observational study from a tertiary referral centre included 263 patients diagnosed before and after the introduction of an intervention to reduce clinical time intervals, the Cancer Patient Pathway (CPP). The CPP included fast-track referral and set time-frames for units participating in cancer diagnosis and treatment, and was introduced for penile cancer in Denmark on 1 January 2009. Median time intervals (in calendar days) with interquartile range were the main outcome measure. RESULTS: A trend towards reduction was observed in all clinical time intervals, with a statistically significant reduction in the system interval (p = 0.01) and tertiary centre interval (p < 0.0001). The proportion of patients treated within the maximum accepted time-frame of 37 days after referral steadily increased after implementation of the CPP. In particular, unjustified waiting time was reduced significantly. This was mainly achieved through pre-booking of appointments and diagnostic time slots by a dedicated clinical coordinator. CONCLUSIONS: To the authors' knowledge, this is the first study examining the feasibility and impact of an intervention to reduce clinical time intervals in penile cancer. The Danish CPP was successful in reducing system and tertiary centre intervals. Future interventions need to address the long patient interval. Longer follow-up is needed to study the impact of CPP on mortality.

DaPeCa-2: Implementation of fast-track clinical pathways for penile cancer shortens waiting time and accelerates the diagnostic process--A comparative before-and-after study in a tertiary referral centre in Denmark.

OBJECTIVE: The aim of this study was to examine the feasibility and impact of a fast-track referral pathway on clinical time intervals in penile cancer. MATERIALS AND METHODS: This observational study from a tertiary referral centre included 263 patients diagnosed before and after the introduction of an intervention to reduce clinical time intervals, the Cancer Patient Pathway (CPP). The CPP included fast-track referral and set time-frames for units participating in cancer diagnosis and treatment, and was introduced for penile cancer in Denmark on 1 January 2009. Median time intervals (in calendar days) with interquartile range were the main outcome measure. RESULTS: A trend towards reduction was observed in all clinical time intervals, with a statistically significant reduction in the system interval (p = 0.01) and tertiary centre interval (p < 0.0001). The proportion of patients treated within the maximum accepted time-frame of 37 days after referral steadily increased after implementation of the CPP. In particular, unjustified waiting time was reduced significantly. This was mainly achieved through pre-booking of appointments and diagnostic time slots by a dedicated clinical coordinator. CONCLUSIONS: To the authors' knowledge, this is the first study examining the feasibility and impact of an intervention to reduce clinical time intervals in penile cancer. The Danish CPP was successful in reducing system and tertiary centre intervals. Future interventions need to address the long patient interval. Longer follow-up is needed to study the impact of CPP on mortality.

Cancer Patient Pathways shortens waiting times and accelerates the diagnostic process of suspected sarcoma patients in Denmark.

Cancer Patient Pathways (CPPs) for suspected cancer were implemented in Denmark to reduce waiting times for cancer diagnosis and treatment. Our study describes developments in time intervals and tumour size in a natural experiment before and after implementation of the CPP for sarcomas (January 1st, 2009). Medical files for patients referred with suspected sarcoma from other hospitals to Aarhus Sarcoma Centre during 2007-2010 (n=1126) were reviewed for data on milestones, time intervals, performed diagnostics, and tumour size. Results showed a statistically significant reduction in median number of work days in the phase "referral to first appointment" for all patients. For bone sarcomas, median time was significantly reduced from 11 to five work days in the phase "first appointment to decision of treatment", for soft tissue sarcomas it was reduced from 28 to 18 work days in the phase "referral to start of treatment". Passive waiting time was reduced, and delays in the fast-track programme were caused mostly by supplementary diagnostics. Median tumour size for soft tissue sarcomas was reduced from 7.0 to 4.9cm, possibly a secondary effect of increased awareness. CPPs have accelerated the diagnostic process for sarcomas, and our results may aid international development of similar initiatives.