Prognostic consequences of implementing cancer patient pathways in Denmark: a comparative cohort study of symptomatic cancer patients in primary care

Abstract

BackgroundCancer Patient Pathways (CPPs) were introduced in 2000–2015 in several European countries, including Denmark, to reduce the time to diagnosis and treatment initiation and ultimately improve patient survival. Yet, the prognostic consequences of implementing CPPs remain unknown for symptomatic cancer patients diagnosed through primary care.We aimed to compare survival and mortality among symptomatic patients diagnosed through a primary care route before, during and after the CPP implementation in Denmark.MethodsBased on data from the Danish Cancer in Primary Care (CaP) Cohort, we compared one- and three-year standardised relative survival (RS) and excess hazard ratios (EHRs) before, during and after CPP implementation for seven types of cancer and all combined (n = 7725) by using life-table estimation and Poisson regression. RS estimates were standardised according to the International Cancer Survival Standard (ICSS) weights. In addition, we compared RS and EHRs for CPP and non-CPP referred patients to consider potential issues of confounding by indication.ResultsIn total, 7725 cases were analysed: 1202 before, 4187 during and 2336 after CPP implementation. For all cancers combined, the RS3years rose from 45% (95% confidence interval (CI): 42;47) before to 54% (95% CI: 52;56) after CPP implementation. The excess mortality was higher before than after CPP implementation (EHR3years before vs. after CPP = 1.35 (95% CI: 1.21;1.51)). When comparing CPP against non-CPP referred patients, we found no statistically significant differences in RS, but we found lower excess mortality among the CPP referred (EHR1year CPP vs. non-CPP = 0.86 (95% CI: 0.73;1.01)).ConclusionWe found higher relative survival and lower mortality among symptomatic cancer patients diagnosed through primary care after the implementation of CPPs in Denmark. The observed changes in cancer prognosis could be the intended consequences of finding and treating cancer at an early stage, but they may also reflect lead-time bias and selection bias. The finding of a lower excess mortality among CPP referred compared to non-CPP referred patients indicates that CPPs may have improved the cancer prognosis independently.

Time intervals and routes to diagnosis for lung cancer in 10 jurisdictions: cross-sectional study findings from the International Cancer Benchmarking Partnership (ICBP)

“…The latter includes PCP access to fast-track diagnostic work-up. 46 The findings are in keeping with higher relative survival and lower mortality in Denmark among symptomatic cancer patients diagnosed through primary care after the implementation of CPPs and with the accelerated increase in 5-year survival among Danish patients with lung cancer diagnosed in 2010-2014 when compared with patients from earlier time periods. 47 48 While there is some inherent lead-time bias, the findings highlight the importance and feasibility of a timely diagnosis of lung cancer.…”

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Pathways to Diagnosis for Teenagers and Young Adults with Cancer in European Nations: A Pilot Study

“…This asymmetric and skewed distribution may indicate a sporadic not a systematic prolongation of the process. This is reflected in the recent 'three-legged' approach to health service improvement in Denmark [38,39]. The characteristics and risk factors associated with this could be examined in a larger study, focusing upon the cancers where data most strongly indicates a prolonged pathway is detrimental [40].…”

Concordance between Optimal Care Pathways and colorectal cancer care: Identifying opportunities to improve quality and reduce disparities

“…Several countries have adopted cancer care pathway policies . There is increasing evidence that adherence to pathways is associated with improved outcomes, including increased survival and lower costs of care . In October 2016, the Australian government endorsed Optimal Care Pathways (OCPs) for 16 cancer types .…”