Diagnostic Intervals in Breast, Colorectal, Lung, Pancreatic, Oesophageal and Gastric Cancers and : Database Study Richard D NealBangor University Nafees U Din Bangor University William Hamilton Peninsula Medical School Greg RubinDurham University
Shorter ‘diagnostic intervals’ (the time period between the first presentation of potential cancer symptoms, usually to primary care, and diagnosis) may lead to earlier stage diagnoses and better cancer outcomes. As part of the National Awareness and Early Diagnosis Initiative (NAEDI), we undertook this baseline study. The General Practice Research Database (GPRD) in the UK is a well-validated dataset for research in primary care. Background
Diagnostic interval Onset of symptoms Presentation of symptoms Date of diagnosis Time Diagnostic interval
To determine and compare diagnostic intervals in two time periods ( & before and after the introduction of the 2005 NICE Referral Guidelines for Suspected Cancer) To create baselines for future comparisons. Aims
Patient cohorts Symptomatic patients of incident cancer aged ≥ 40 diagnosed between: – inclusive (breast n= 733, colorectal n= 1825, lung n= 1671, pancreas n= 409, oesophagus n=555, stomach n=415) – inclusive (breast n= 902, colorectal n= 2716, lung n= 2567, pancreas 524, oesophagus n=761, stomach n=562) Patients who did not present with symptoms (e.g. emergency admissions) were excluded. Methods
Symptoms: of primary local and regional disease for each cancer, and with a published independent association with cancer of greater than 0.5% for a patient presenting to primary care, based upon: Systematic review evidence Single studies using rigorous methods Consensus statements Additionally for each cancer: anaemia, anorexia, fatigue, and weight loss Each symptom then classified into whether ‘NICE qualifying’ or not, based upon whether it justified urgent referral Methods
Diagnostic interval: The duration in days from first presentation of cancer related symptom(s) in primary care to date of diagnosis. Data analysis: Diagnostic intervals in the two cohorts were compared and are presented here for: First symptomatic presentation NICE qualifying symptoms, divided into three groups : 1.Initial presentation of a NICE qualifying symptom (‘always NICE’) 2.Initial presentation of a NICE non-qualifying symptom, followed by a NICE qualifying symptom prior to diagnosis (‘became NICE’) 3.No NICE qualifying symptoms prior to diagnosis (‘never NICE’) Methods
Median diagnostic intervals reduced for all six cancers between & : 8% (2 days) for breast 25% (21 days) for colorectal 3% (4 days) for lung 18% (11 days) for pancreatic 19% (11 days) for oesophageal 12% (11 days) for gastric This difference was statistically significant for colorectal, pancreatic and oesophageal cancers. First presentation of any cancer symptom
Both cohorts had long diagnostic intervals towards the third and fourth quartiles. 90 th centile diagnostic intervals
Overlaid histograms Breast Colorectal Date of diagnosis
Diagnostic intervals by NICE categories
Diagnostic intervals can and do change over time. These reduced for all cancers, but significantly for only colorectal, pancreas and oesophagus; but they still remain high with long tails to the distribution. The reduction shifted patients from 3-4 months to 1-2 months. There is significant room for improvement in reducing diagnostic intervals, especially for tails of distributions and for NICE non-qualifying symptoms. The reduction in diagnostic intervals looks to be partly as a result of a major policy initiative; that of implementation of the 2005 Referral Guidelines for Suspected Cancer. Analysis of symptoms by NICE urgent referral qualifying criteria shows that the guidelines may have made easier diagnosis quicker; and diagnostic intervals for ‘non-red flag’ symptoms remain high or have increased for some cancers. Data on other cancers to follow. The effect of reduction in diagnostic intervals on stage at diagnosis and survival remains unknown at present – but we are addressing this… Conclusions