Examining methodology to identify patterns of consulting in primary care for different groups of patients before a diagnosis of cancer: An exemplar applied to oesophagogastric cancer

Background Increased time-to-diagnosis in sarcoma is associated with poor prognosis and patient outcomes. Research is needed to identify if opportunities to expedite the diagnosis of sarcoma in general practice (GP) exist. Aim To examine pre-diagnostic GP clinical activity prior to sarcoma diagnosis. Design and Setting An Australian retrospective cohort study using hospital registry data (Australian Comprehensive Cancer Outcomes and Research Database) linked to two primary care datasets (Patron and MedicineInsight). Method The frequency of GP healthcare utilisation events (GP attendances, prescriptions, blood test and imaging requests) were compared in 377 soft tissue sarcoma (STS) and 64 bone sarcoma (BS) patients in the year pre-diagnosis. Poisson regression models were used to calculate monthly incidence rates and rate ratios (IRR) for the 24 months pre-diagnosis and estimate inflection points for when healthcare use starts to increase from baseline. Results In the six months pre-diagnosis sarcoma patients had a median of 3-4 GP attendances, a third had a GP imaging request (33% BS and 36% STS), and one in five had multiple imaging requests (19% BS and 21% STS). GP imaging requests progressively increased up to 8-fold from 6 months prior to sarcoma diagnosis (IRR 8.43 95%CI 3.92-18.15, p<0.001) and GP attendances increased from 3 months pre-diagnosis. Conclusion Sarcoma patients have increased GP clinical activity from 6 months pre-diagnosis, indicating a diagnostic window where potential opportunities exist for earlier diagnosis. Interventions to help identify patients and promote appropriate use of imaging and direct specialist centre referrals could improve earlier diagnosis and patient outcomes.

Section: Strengths and Limitationsmentioning

confidence: 88%

Clinical activity in general practice before sarcoma diagnosis: an Australian cohort study

Rafiq,

de Boer,

Mar

et al. 2024

“…As the concept of ‘diagnostic windows’ has not been widely considered outside cancer, most studies ( n = 24) did not use statistical methods to formally estimate diagnostic window length, instead relying on visual identification, which may be suboptimal. 42 A JBI critical appraisal tool was used to assess study quality. Some studies did not report sufficient statistics for the current review’s purpose, and it was therefore necessary to rely on text narrative information or exhibits, which sometimes lacked detail.…”

Section: Discussionmentioning

confidence: 99%

“…As the concept of 'diagnostic windows' has not been widely considered outside cancer, most studies (n=24) did not use statistical methods to formally estimate diagnostic window length, instead relying on visual identification, which may be suboptimal [42]. A modified JBI critical appraisal tool was used to assess study quality.…”

Section: Strengths and Limitationsmentioning

confidence: 99%

Diagnostic windows in non-neoplastic diseases: a systematic review

Whitfield¹,

White

Denaxas³

et al. 2023

Background: Investigating changes in pre-diagnostic healthcare utilisation can help identify how much earlier conditions could be diagnosed. Such ‘diagnostic windows’ are established for cancer but remain relatively unexplored for non-neoplastic conditions. Aim: To extract evidence on the presence and length of diagnostic windows for non-neoplastic conditions. Design and setting: Systematic review of studies of pre-diagnostic healthcare utilisation. Method: A search strategy was developed to identify relevant studies from PubMed and Connected Papers. Data was extracted on pre-diagnostic healthcare use and evidence of diagnostic window presence and length was assessed. Results: Of 4,340 studies screened, 27 were included, covering 17 non-neoplastic conditions, including both chronic (e.g., Parkinson’s disease) and acute conditions (e.g., stroke). Pre-diagnostic healthcare events included primary care encounters and presentations with relevant symptoms. For 9 conditions, sufficient evidence to determine diagnostic window presence and length was available, ranging from 28 days (herpes simplex encephalitis) to 9 years (ulcerative colitis). For the remaining conditions, diagnostic windows were likely to be present, but insufficient study duration was often a barrier to robustly determining their length. Conclusion: Evidence of changing healthcare use before diagnosis exists for many non-neoplastic conditions, establishing that early diagnosis is possible, in principle. In particular, some conditions, such as coeliac disease, may be detectable in certain ways more than a decade earlier than they are currently diagnosed. Further research is required to accurately estimate diagnostic windows, determine how much earlier diagnosis may be possible, and how this might be achieved.

“…A detailed explanation of the method has been published. 18 We considered bladder, renal cancer and UTUC separately in the analysis because they can present differently and therefore associated prescriptions may differ. Inflection points were estimated for all combined prescriptions for each clinical feature (e.g.…”

Section: Prescription Categoriesmentioning

confidence: 99%

“…This direct maximum likelihood method is less prone to bias than similar methods when examining changes in rates of clinical events. 18 For the purposes of this study, having controls would have added little other than to account for general trends in prescribing in the primary care population over time. We used data from patients diagnosed up to December 2015.…”

Section: Strengths and Limitationsmentioning

confidence: 99%

Pre-diagnostic prescription patterns in bladder and renal cancer: a longitudinal linked data study

Funston,

Moullet,

Mounce

et al. 2023

Self Cite

Background: Understanding pre-diagnostic prescribing activity could reveal windows during which more timely cancer investigation and detection may occur. Aim: To examine prescription patterns for common urological clinical features prior to renal and bladder cancer diagnoses. Design and setting: We performed a retrospective cohort study using electronic primary care and cancer registry data on patients with bladder and renal cancer diagnosed between April 2012–December 2015 in England. Method: We analysed primary care prescriptions up to 2 years pre-diagnosis for five groups of clinical features (irritative urological symptoms, obstructive symptoms, urinary tract infections, genital infections, atrophic vaginitis). Poisson regressions estimating the inflection point, from which the rate of prescriptions increased from baseline, were used to identify the start of diagnostic windows during which cancer could be detected. Results: 48,094 prescriptions for 5,322 patients were analysed. Inflection points for an increase in UTI prescriptions were identified 9 months pre-diagnosis for renal (CI:5.3–12.7) and bladder (CI:7.4–10.6) cancers. For bladder cancer, the change in UTI antibiotic prescription rates occurred four months earlier in women (11 months, CI:9.7–12.3) than men (7 months, CI:5.4–8.6). No inflection points were identified, and so no diagnostic windows could be defined, for other clinical features. Conclusion: Prescription rates for UTIs increased 9 months before bladder and renal cancer diagnosis, indicating that there is potential to expedite diagnosis of these cancers in patients presenting with features of UTI. The greatest opportunity for more timely diagnosis may be in women with bladder cancer, who experienced the earliest increase in UTI prescription rate.