Mental Health Morbidities and Time to Cancer Diagnosis Among Adults With Colon Cancer in England

Abstract

ImportanceMental health morbidity (MHM) in patients presenting with possible cancer symptoms may be associated with prediagnostic care and time to cancer diagnosis.ObjectiveTo compare the length of intervals to cancer diagnosis by preexisting MHM status in patients who presented with symptoms of as-yet–undiagnosed colon cancer and evaluate their risk of emergency cancer diagnosis.Design, Setting, and ParticipantsThis cohort study was conducted using linked primary care data obtained from the population-based Clinical Practice Research Datalink, which includes primary care practices in England, linked to cancer registry and hospital data. Included participants were 3766 patients diagnosed with colon cancer between 2011 and 2015 presenting with cancer-relevant symptoms up to 24 months before their diagnosis. Data analysis was performed in January 2021 to April 2022.ExposuresMental health conditions recorded in primary care before cancer diagnosis, including anxiety, depression, schizophrenia, bipolar disorder, alcohol addiction, anorexia, and bulimia.Main Outcomes and MeasuresFast-track (also termed 2–week wait) specialist referral for investigations, time to colonoscopy and cancer diagnosis, and risk of emergency cancer diagnosis.ResultsAmong 3766 patients with colon cancer (median [IQR] age, 75 [65-82] years; 1911 [50.7%] women ), 623 patients [16.5%] had preexisting MHM recorded in primary care the year before cancer diagnosis, including 562 patients (14.9%) with preexisting anxiety or depression (accounting for 90.2% of patients with preexisting MHM) and 61 patients (1.6%) with other MHM; 3143 patients (83.5%) did not have MHM. Patients with MHM had records of red-flag symptoms or signs (ie, rectal bleeding, change in bowel habit, or anemia) in the 24 months before cancer diagnosis in a smaller proportion compared with patients without MHM (308 patients [49.4%] vs 1807 patients [57.5%]; P < .001). Even when red-flag symptoms were recorded, patients with MHM had lower odds of fast-track specialist referral (adjusted odds ratio [OR] = 0.72; 95% CI, 0.55-0.94; P = .01). Among 2115 patients with red-flag symptoms or signs, 308 patients with MHM experienced a more than 2-fold longer median (IQR) time to cancer diagnosis (326 [75-552] days vs 133 [47-422] days) and higher odds of emergency diagnosis (90 patients [29.2%] vs 327 patients [18.1%]; adjusted OR = 1.63; 95% CI, 1.23-2.24; P < .001) compared with 1807 patients without MHM.Conclusions and RelevanceThis study found that patients with MHM experienced large and prognostically consequential disparities in diagnostic care before a colon cancer diagnosis. These findings suggest that appropriate pathways and follow-up strategies after symptomatic presentation are needed for earlier cancer diagnoses and improved health outcomes in this large patient group.

Where are the inequalities in colorectal cancer care in a country with universal healthcare? A systematic review and narrative synthesis

“…The characteristics of the included studies are summarised in online supplemental appendix S7. The system interval was examined in 12 studies, with 7 different time points evaluated, summarised in figure 2 12–23. In total, 15 studies reported the receipt of surgery,19 20 24–36 7 studies evaluated surgical variation,37–43 14 studies reported the receipt of chemotherapy,19 20 24–27 44–51 7 reported the receipt of radiotherapy19 20 25–27 43 52 and 2 reported the receipt of any treatment 17 46…”

“…In total, 32 of the 41 studies adjusted or stratified for at least one other factor 12–26 32–41 44–49 51. The remaining nine studies provided unadjusted rates 27–31 42 43 50 52…”

“…One study demonstrated an association between deprivation and a longer interval in two of three econometric analyses (pre-to-post difference-in-differences 95% CI −0.03 to 0.2 and p=0.147 or event-study difference-in-differences 95% CI 0.002 to 0.136 and p=0.043 or semiparametric varying-coefficient analysis significance stated but not reported) 21. The other two studies conducted quantile regression, focusing on the median and 75th centiles, adjusting for age, comorbidities, sex and type of symptom 22 23. Both studies demonstrated an association between the most deprived quintile and a longer first presentation to diagnosis interval for patients with colon cancer (eg, adjusted median interval of 204 vs 126 days, p=0.04) 22.…”

The Interface Between Colon Cancer and Mental Health Morbidities

“…Increased screening may over time be associated with fewer diagnoses based on clinical presentation, but this will not remove the need for clinical vigilance, enhanced safety netting, and triage testing and appropriate referral. As we now know, 1 this is even more applicable for patients with concurrent mental health problems, who may need specific targeted interventions to improve screening uptake and symptomatic presentation to primary care.…”

“…In this landmark study by Benitez Majano et al, the authors use linked primary care data to study pathways to diagnosis and diagnostic delay and the association with mental health conditions. Unsurprisingly, patients with a coexistent mental health diagnosis experienced diagnostic delay.…”