Missed cancer in the Danish head and neck cancer fast-track program: results from a tertiary cancer center.

BACKGROUND: The Danish head and neck cancer fast-track program is a national standardized pathway aiming to reduce waiting time and improve survival for patients suspected of cancer in the head and neck (HNC). Until now, the frequency of missed cancer in the fast-track program has not been addressed. A missed cancer leads to treatment delay and may cause disease progression and worsening of prognosis. The study objective was to estimate the frequency of patients with missed cancers in the Danish HNC fast-track program and to evaluate the accuracy of the program. MATERIALS AND METHODS: Patients who were rejected from the HNC fast-track program because cancer was not found between 1 July 2012 and 31 December 2018 at Odense University Hospital, Denmark were included and followed for three years. Patients were categorized into groups depending on the diagnostic evaluation. Group 1 included patients evaluated with standard clinical work-up without imaging and biopsy. Group 2 included patients evaluated with imaging and/or biopsy in addition to the standard clinical work-up. The local cancer database and electronic patient records were reviewed to determine if a missed cancer had occurred within the follow-up period. RESULTS: A total of 8345 HNC fast-track courses were initiated during the study period. 1499 were patients suspected of recurrent cancer and were excluded leaving 6846 patients to be assessed for eligibility. Of these, 3752 patients were rejected because cancer was not found. Ten patients were subsequently diagnosed with cancer within the follow-up period resulting in an overall frequency of 0.15%. For group 1 and 2, the frequency was 0.04% and 0.10%, respectively. The sensitivity of the fast-track program was 99.67% and the negative predictive value was 99.73%. CONCLUSION: The frequency of missed cancer in a tertiary HNC center following the Danish fast track program is low.

Sensitivity and missed cancer rate in the symptomatic breast clinic-A retrospective cohort study of 40 323 patients.

INTRODUCTION: Symptomatic presentations account for the majority of invasive breast cancer diagnoses. While the National Health Service Breast Screening Programme is subjected to strict quality control, no such system for performance monitoring exists in the symptomatic clinic. We assess the sensitivity of cancer detection and missed cancer rate for symptomatic breast patients to benchmark future outcome measures. METHODS: A retrospective cohort study of patients attending the symptomatic breast clinic between October 2013 and October 2018 was performed. Patients with new cancer diagnoses were identified and screened for those who had presented to the department within the 3 years prior to their diagnosis. From this, the sensitivity and missed cancer rate were calculated. RESULTS: About 40 323 patients were seen over the 5-year study period. About 2155 new cancers were diagnosed, with 2033 identified at their initial clinic attendance. A further 122 patients had cancer diagnosed on a subsequent appointment, of which 23 patients were considered to have had a delay in diagnosis. The sensitivity of the one-stop symptomatic breast clinic was therefore 99.0%, and the missed cancer rate was 0.06% over 5 years. CONCLUSION: The missed cancer rate reported in this study is favorable compared to the outcomes reported in the National Health Service Breast Screening Programme and superior to the only other study reporting outcomes on a much smaller cohort. The unit in question therefore is performing exceptionally against current standards and sets a benchmark against which future performance can be measured.

Audit of Prior Screening Mammograms of Screen-Detected Cancers: Implications for the Delay in Breast Cancer Detection.

When cancer is detected in a screening mammogram, on occasion retrospective review of prior screening (pre-index) mammograms indicates a likely presence of cancer. These missed cancers during pre-index screens constitute a delay in detection and diagnosis. This study was undertaken to quantify the missed cancer rate by auditing pre-index screens to improve the quality of mammography screening practice. From a cohort of 135 screen-detected cancers, 120 pre-index screening mammograms could be retrieved and served as the study sample. A consensus read by 2 radiologists who interpreted the pre-index screens in an unblinded manner with full knowledge of cancer location, cancer type, lesion type, and pathology served as the truth or reference standard. Five radiologists interpreted the pre-index screens in a blinded manner. Established performance metrics such as sensitivity and specificity were quantified for each reader in interpreting these pre-index screens in a blinded manner. All five radiologists detected lesions in 8/120 (6.7%) screens. Excluding the 2 readers whose performance was close to random, all the 3 remaining readers detected lesions in 13 pre-index screens. This indicates that there is a delay in diagnosis by at least one cycle from 8/120 (6.7%) to 13/120 (10.8%). There were no observable trends in terms of either the cancer type or the lesion type. Auditing prior screening mammograms in screen-detected cancers can help in identifying the proportion of cases that were missed during interpretation and help in quantifying the delay in breast cancer detection.

Gastric Cancers Missed at Upper Endoscopy in Central Norway 2007 to 2016-A Population-Based Study.

BACKGROUND: The rates of missed gastric cancers (MGC) at upper endoscopy (UE) has been reported at 5-10% in Western countries. We aimed to calculate the rate of MGC and identify factors associated with MGC. METHODS: Retrospective population-based cohort study including 730 patients diagnosed with gastric adenocarcinoma in Central Norway 2007-2016. MGCs were incident gastric adenocarcinomas diagnosed 6-36 months after a previous UE. Factors associated with MGC were examined. Definitely missed (UE 6-12 months prior) and potentially missed (UE 12-36 months prior) MGCs were compared. RESULTS: Sixty-seven (9.2%) of 730 gastric cancers were MGC. MGC were associated with localization (p = 0.009) and more frequent in the corpus, Lauren's histological type (p = 0.028) and diffuse type more prevalent, and previous Billroth 2-operation (14.9% vs. 4.7%, p = 0.001). MGCs were diagnosed at earlier stages (p = 0.037). An ulceration was more common in patients with definitely missed than potentially MGC (40.9% vs. 17.8%, p = 0.041). CONCLUSIONS: MGC accounted for 9.2% of gastric cancers in Central Norway. MGC were associated with localization in the corpus, Lauren´s diffuse type and previous Billroth-2-operation. Intensified follow-up and adequate biopsy sampling of patients with gastric ulcerations could reduce the rate of missed gastric cancers.

Characteristics and consequences of missed gastric cancer: A multicentric cohort study.

BACKGROUND: Missed gastric cancer (MGC) is poorly documented in Mediterranean populations. AIMS: (1) To assess the rate, predictors and survival of MGC. (2) To compare MGC and non-MGC tumors. METHODS: This is a retrospective-cohort study conducted at four centers. MGC was defined as cancer detected within three years after negative esophagogastroduodenoscopy. Gastric adenocarcinomas diagnosed between 2008-2015 were included. Patients with no follow-up were excluded. RESULTS: During the study period 123,395 esophagogastroduodenoscopies were performed, with 1374 gastric cancers being diagnosed (1.1%). A total of 1289 gastric cancers were finally included. The overall rate of MGC was 4.7% (61/1289, 3.7-6%). A negative esophagogastroduodenoscopy in MGC patients was independently associated with PPI therapy (p < 0.001), previous Billroth II anastomosis (p = 0.002), and lack of alarm symptoms (p < 0.001). The most frequent location for MGC was the gastric body(52.4%). MGCs were smaller than non-MGCs (31 vs 41 mm, p = 0.047), more often flat or depressed (p = 0.003) and less likely to be encountered as advanced disease. Overall 2-year survival was similar between MGC (34.1%) and Non-MGC (35.3 %) (p = 0.59). CONCLUSION: MGC accounted for nearly five percent of newly-diagnosed gastric adenocarcinomas. Overall survival was poor and not different between MGC and non-MGC.

Rate of missed oesophageal cancer at routine endoscopy and survival outcomes: A multicentric cohort study.

Background: Missed oesophageal cancer (MEC) at upper gastrointestinal endoscopy (UGE) is poorly documented. Objective: The objectives of this study were: (1) to assess the rate, predictors and survival of MEC; (2) to compare MEC and non-MEC tumours. Methods: This was a retrospective cohort study conducted at four tertiary centres. Oesophageal cancers (ECs) diagnosed between 2008 and 2015 were included. Patients with a premalignant condition (Barrett, achalasia), prior diagnosis of EC or oesophagogastric junction tumour of gastric origin were excluded. MEC was defined as EC detected within 36 months after negative UGE. Results: 123,395 UGEs were performed during the study period, with 502 ECs being diagnosed (0.4%). A total of 391 ECs were finally included. Overall MEC rate was 6.4% (95% confidence intervals (CI): 4.4-9.3%). The interval between negative and diagnostic UGE was less than 2 years in 84% of the cases. Multivariate analysis showed that a negative endoscopy was associated with proton pump inhibitor (PPI) therapy and less experienced endoscopists. MEC was smaller than non-MEC at diagnosis (25 versus 40 mm, p = 0.021), more often flat or depressed (p = 0.013) and less frequently diagnosed as metastatic disease (p = 0.013). Overall 2-year survival rate was similar for MEC (20%) and non-MEC (24.1%) (p = 0.95). Conclusions: MEC accounted for 6.4% of all ECs and was associated with poor survival. High-quality UGE and awareness of MEC may help to reduce its incidence.