Henry Jensen [Read-Only] · D o v } u u o ] P v v ð U ð ñ ñ ô ï ~ í X õ '/ î ô ~ ï ï X...

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Funded by: The Danish Cancer Society Risk of cancer and repeated urgent referral - after a negative investigation for cancer Ninna Nielsen, MD Professor Peter Vedsted Henry Jensen, PhD

Transcript of Henry Jensen [Read-Only] · D o v } u u o ] P v v ð U ð ñ ñ ô ï ~ í X õ '/ î ô ~ ï ï X...

Page 1: Henry Jensen [Read-Only] · D o v } u u o ] P v v ð U ð ñ ñ ô ï ~ í X õ '/ î ô ~ ï ï X ó ò ~ ó X î E^ ~ ] v î U ï õ î í í ï ~ ð X ó > µ v P ï ô ~ ï ï

Funded by: The Danish Cancer Society

Risk of cancer and repeated urgent referral - after a negative investigation for cancer

Ninna Nielsen, MD

Professor Peter Vedsted

Henry Jensen, PhD

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Funded by: The Danish Cancer Society

General Practice:Patients with

symptoms/signs that could indicate disease

Referral to the non-specific signs and symptoms CPP

Blood panel

Referral to an organ specific standardized Cancer Patient

Pathway (CPP)

“Easy” access to diagnostic investigations

Organ-specificCPP

Diagnostic Centre

General practice holds responsibility for patient Hospital holds responsibility

Vedsted, Olesen., Br J Cancer. 2015

Cancer diagnostics in Denmark - schematic

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Funded by: The Danish Cancer Society

Danish Cancer Patient pathways (CPPs)

• 28 organ-specific CPPs• Implemented in 2008/09

• Revised in 2016

• Uniform and more timely diagnosis and treatment of cancer

• Descriptions of selected symptoms that may raise cancer suspicion

• Descriptions of medical procedures (secondary health-care sector)

• Time frames for all phases

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Funded by: The Danish Cancer Society

Danish CPP UK (urgent referral / 2WW)

Referral criteria All patients above 40:

Rectal bleeding

Change in bowel habit for 4 weeks

Unexplained haemorrhage anaemia

Significant general symptoms (e.g.

weight loss, stomach pain)

All patients as follows:

Aged 40 or older with unexplained weight loss AND

abdominal pain

Age 50 or older with unexplained rectal bleeding

Aged 60 with iron-defiency anaemia OR changed

bowel habits

Positive test for occult blood in faeces

Referral time 9 days 14 days (2 weeks)

Hospital diagnostics

(complete)

18 days n/a

Total time

(referral to treatment)

37 days (operation, chemotherapy)

41 days (radiotherapy)

62 days

Danish CRC-CPP vs. UK’s NICE guidelines

NICE. NICE Guideline no.12 - Suspected cancer: recognition and referral, 2015 Danish National Board of Health. Integrated Cancer Patient Pathway – Colorectal Cancer, 2016

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Funded by: The Danish Cancer Society

Any problems?

• Difficult task for the GP to identify the patients who might have cancer

• Alarm symptoms of cancer are highly prevalent among patients

(Nielsen et al. Ugeskr Laeger 2010; Elnegaard et al. BMC Pub Health 2015)

• A single alarm symptom has low positive predictive value (PPV) for cancer

(Hamilton. Br J Cancer 2009)

• 40-50% of cancer patients present with vague non-specific symptoms (Jensen et al BMC Cancer 2014; Nielsen et al. Ugeskr Laeger 2010)

• Difficult for the GP to choose the correct organ-specific CPP

• 88% of cancers are diagnosed through at least oneCPP (Danish Health Data Agency 2016)

• Unknown how many?

Symptom at first consultation %

Alarm symptom 50

Serious, unspecific 15

Vague, non-specific 35

Jensen et al. BMC Cancer 2014; Nielsen el al. Ugeskr Læger. 2010; Hvidberg et al. [in preparation]

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Funded by: The Danish Cancer Society

Aims

1. To estimate the proportion of patients who underwent a second CPP and were diagnosed with cancer- within six months after ending an initial CPP with a negative diagnosis

2. To investigate potential overlaps between the CPPs patients were referred to

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Funded by: The Danish Cancer Society

The study

• Cohort study • Danish national registries • Six months follow-up

• Eligible patients:• Completed a first-time CPP with no verified cancer diagnosis• 1 January 2014 - 30 June 2015

• Outcomes• Second CPP• Subsequent cancer diagnosis

• During second CPP• Overall

• Death (not presented today)

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Funded by: The Danish Cancer Society

Patients included

Male Female Total

n (%) n (%) n (%)

Total 48,653 (44.2) 61,345 (55.8) 109,998 (100)

Age group (years)

18-44 6,961 (14.3) 12,865 (21.0) 19,826 (18.0)

45-54 8,342 (17.1) 13,672 (22.3) 22,014 (20.0)

55-64 11,789 (24.2) 12,935 (21.1) 24,724 (22.5)

65-74 13,512 (27.8) 13,111 (21.4) 26,623 (24.2)

75-84 6,757 (13.9) 7,046 (11.5) 13,803 (12.5)≥85 1,292 (2.7) 1,716 (2.8) 3,008 (2.7)

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Funded by: The Danish Cancer Society

First CPP with negative cancer test result- by anatomical site

Anatomical site of CPP Male Female Totaln (%) n (%) n (%)

Gastrointestinal (GI) system 19,139 (39.3) 20,300 (33.1) 39,439 (35.9)Breast 481 (1.0) 15,666 (25.5) 16,147 (14.7)Urinary system 8,541 (17.6) 4,232 (6.9) 12,773 (11.6)Lung 6,888 (14.2) 5,832 (9.5) 12,720 (11.6)Female cancers 7,077 (11.5) 7,077 (6.4)Head and neck 3,266 (6.7) 3,364 (5.5) 6,630 (6.0)Male cancers 6,401 (13.2) 6,401 (5.8)Melanoma, malignant 1,895 (3.9) 2,560 (4.2) 4,455 (4.1)CNS (brain) 1,018 (2.1) 1,374 (2.2) 2,392 (2.2)Lymphatic and blood systems 610 (1.3) 516 (0.8) 1,126 (1.0)Others 414 (0.9) 424 (0.7) 838 (0.8)

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Funded by: The Danish Cancer Society

What happens within 6 months

CANCER diagnoses Totaln (%)

Total 693 (0.6)Men 303 (0.6)Women 390 (0.6)

Additional CPPs Total Men Womenn (%) n (%) n (%)

1 6,130 (5.6) 2,972 (6.1) 3,158 (5.1)2 517 (0.5) 270 (0.6) 247 (0.4)≥3 50 (0.0) 22 (0.0) 28 (0.0)

Total 6,697 (6.1) 3,264 (6.7) 3,433 (5.6)

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Funded by: The Danish Cancer Society

Initial CPP Second CPPn n (%) most prevalent New cancer2

N (%) n (%)3

GI 39,439 2,782 (7.1) GI 1,386 (49.8) 112 (4.0)Breast 16,147 352 (2.2) GI 123 (34.9) 19 (5.4)Urinary system 12,773 817 (6.4) GI 348 (42.6) 40 (4.9)Lung 12,720 908 (7.1) GI 357 (39.3) 37 (4.1)Female cancers 7,077 521 (7.4) GI 205 (39.3) 27 (5.2)Head and neck 6,630 673 (10.2) Lymphatic & blood 262 (38.9) 35 (5.2)Male cancers 6,401 249 (3.9) Urinary system 117 (47) 8 (3.2)Melanoma malignant 4,455 83 (1.9) GI 28 (33.7) 6 (7.2)CNS (brain) 2,392 113 (4.7) Lung 38 (33.6) <5 n/a1

Lymphatic & blood 1,126 126 (11.2) Lymphatic & blood 32 (25.4) 7 (5.6)Others 838 73 (8.7) Lymphatic & blood 30 (41.1) <5 n/a1

Overall 109,988 6,697 (6.1) GI 2,782 (41.5) 295 (4.4)

Second CPP within 6 months? – how many? – which ones? – cancers?

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Funded by: The Danish Cancer Society

Initial CPP Second CPPn n (%) most prevalent New cancer2

N (%) n (%)3

GI 39,439 2,782 (7.1) GI 1,386 (49.8) 112 (4.0)Breast 16,147 352 (2.2) GI 123 (34.9) 19 (5.4)Urinary system 12,773 817 (6.4) GI 348 (42.6) 40 (4.9)Lung 12,720 908 (7.1) GI 357 (39.3) 37 (4.1)Female cancers 7,077 521 (7.4) GI 205 (39.3) 27 (5.2)Head and neck 6,630 673 (10.2) Lymphatic & blood 262 (38.9) 35 (5.2)Male cancers 6,401 249 (3.9) Urinary system 117 (47) 8 (3.2)Melanoma malignant 4,455 83 (1.9) GI 28 (33.7) 6 (7.2)CNS (brain) 2,392 113 (4.7) Lung 38 (33.6) <5 n/a1

Lymphatic & blood 1,126 126 (11.2) Lymphatic & blood 32 (25.4) 7 (5.6)Others 838 73 (8.7) Lymphatic & blood 30 (41.1) <5 n/a1

Overall 109,988 6,697 (6.1) GI 2,782 (41.5) 295 (4.4)

Second CPP within 6 months? – how many? – which ones? – cancers?

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Funded by: The Danish Cancer Society

Initial CPP Second CPPn n (%) most prevalent New cancer2

n (%) n (%)3

GI 39,439 2,782 (7.1) GI 1,386 (49.8) 112 (4.0)Breast 16,147 352 (2.2) GI 123 (34.9) 19 (5.4)Urinary system 12,773 817 (6.4) GI 348 (42.6) 40 (4.9)Lung 12,720 908 (7.1) GI 357 (39.3) 37 (4.1)Female cancers 7,077 521 (7.4) GI 205 (39.3) 27 (5.2)Head and neck 6,630 673 (10.2) Lymphatic & blood 262 (38.9) 35 (5.2)Male cancers 6,401 249 (3.9) Urinary system 117 (47) 8 (3.2)Melanoma malignant 4,455 83 (1.9) GI 28 (33.7) 6 (7.2)CNS (brain) 2,392 113 (4.7) Lung 38 (33.6) <5 n/a1

Lymphatic & blood 1,126 126 (11.2) Lymphatic & blood 32 (25.4) 7 (5.6)Others 838 73 (8.7) Lymphatic & blood 30 (41.1) <5 n/a1

Overall 109,988 6,697 (6.1) GI 2,782 (41.5) 295 (4.4)

Second CPP within 6 months? – how many? – which ones? – cancers?

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Funded by: The Danish Cancer Society

Initial CPP Second CPPn n (%) most prevalent New cancer

n (%) n (%)GI 39,439 2,782 (7.1) GI 1,386 (49.8) 112 (4.0)Breast 16,147 352 (2.2) GI 123 (34.9) 19 (5.4)Urinary system 12,773 817 (6.4) GI 348 (42.6) 40 (4.9)Lung 12,720 908 (7.1) GI 357 (39.3) 37 (4.1)Female cancers 7,077 521 (7.4) GI 205 (39.3) 27 (5.2)Head and neck 6,630 673 (10.2) Lymphatic & blood 262 (38.9) 35 (5.2)Male cancers 6,401 249 (3.9) Urinary system 117 (47) 8 (3.2)Melanoma malignant 4,455 83 (1.9) GI 28 (33.7) 6 (7.2)CNS (brain) 2,392 113 (4.7) Lung 38 (33.6) <5 n/aLymphatic & blood 1,126 126 (11.2) Lymphatic & blood 32 (25.4) 7 (5.6)Others 838 73 (8.7) Lymphatic & blood 30 (41.1) <5 n/aOverall 109,988 6,697 (6.1) GI 2,782 (41.5) 295 (4.4)

Second CPP within 6 months? – how many? – which ones? – cancers?

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Funded by: The Danish Cancer Society

Conclusion

• 6% are re-referred to a new organ-specific CPP• Many concern the same anatomical area as the first CPP. • Particularly patients who are initially referred to a GI CPP

seem prone to be re-referred to a GI CPP.

• Referral to a second CPP has a PPV of 4.4% for finding cancer• Some cancers may be missed in the first CPP!• Cancer diagnosis delayed

Is a more broad CPP/urgent referral route needed?- e.g. a gastrointestinal (GI) CPP?

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Funded by: The Danish Cancer Society

The end

Henry Jensen

PhD, M.H.Sc.

[email protected]


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