The Improving Rural Cancer Outcomes (IRCO) Trial: a factorial cluster-randomised controlled trial of a complex intervention to reduce time to diagnosis in rural patients with cancer in Western Australia: a study protocol

Abstract

IntroductionWhile overall survival for most common cancers in Australia is improving, the rural–urban differential has been widening, with significant excess deaths due to lung, colorectal, breast and prostate cancer in regional Australia. Internationally a major focus on understanding variations in cancer outcomes has been later presentation to healthcare and later diagnosis. Approaches to reducing time to diagnosis of symptomatic cancer include public symptom awareness campaigns and interventions in primary care to improve early cancer detection. This paper reports the protocol of a factorial cluster-randomised trial of community and general practice (GP) level interventions to reduce the time to diagnosis of cancer in rural Western Australia (WA).Methods and analysisThe community intervention is a symptom awareness campaign tailored for rural Australians delivered through a community engagement model. The GP intervention includes a resource card with symptom risk assessment charts and local referral pathways implemented through multiple academic detailing visits and case studies. Participants are eligible if recently diagnosed with breast, colorectal, lung or prostate cancer who reside in specific regions of rural WA with a planned sample size of 1350. The primary outcome is the Total Diagnostic Interval, defined as the duration from first symptom (or date of cancer screening test) to cancer diagnosis. Secondary outcomes include cancer stage, healthcare utilisation, disease-free status, survival at 2 and 5 years and cost-effectiveness.Ethics and disseminationEthics approval has been granted by the University of Western Australia and from all relevant hospital recruitment sites in WA.ResultsResults of this trial will be reported in peer-reviewed publications and in conference presentations.Trial registration numberAustralian New Zealand Clinical Trials Registry (ANZCTR). ACTRN12610000872033.

Telehealth allows for clinical trial participation and multimodality therapy in a rural patient with stage 4 non-small cell lung cancer

“…It is well known that geographic distance from urban advanced care centers has a negative impact on cancer survival, leading to limited access to appropriate screening, later stages at diagnosis, and worse overall survival. 3,21,27–29 Multiple Australian studies have demonstrated that lung cancer patients who live further from specialist hospitals with thoracic surgeons on staff have higher cancer related mortality rates. 4,15 This is likely due to the fact that patients admitted to specialist hospitals were more likely to receive a resection, which was similarly associated with improved survival.…”

“…1,2 Survival outcomes are reduced in patients from rural environments, often due to delays in diagnosis, treatment, and follow up as well as unavailability of advanced care including multimodality treatment options and enrollment in clinical trials. 3–6 Systemic therapy is the primary method of treatment in these patients with local or distant metastatic disease, and when combined with appropriate surgical resection can lead to significantly improved survival rates. 7 …”

Evidence-practice gaps in lung cancer: A scoping review

“…Intervention studies directed at trying to educate people about lung cancer signs and symptoms (Emery et al, 2014;Smith et al, 2013) are very recent. System level interventions seeking to improve diagnostic processes include policy change such as the UK's 2-week-wait referral pathway (Neal et al, 2014) …”

Improving early diagnosis of symptomatic cancer

“…65,66 Whether raising awareness of individual symptoms, or symptom combinations, of other less common cancers will also promote more timely help-seeking currently remains unclear. 5 Cancer h literacy strongly associated with disadvantaged socio-economic and ethnic minority groups. 67 Linking information on awareness with other healthcare activities awareness: data from a trial that involved offering information about symptoms of breast cancer to women attending breast screening revealed an increase in the proportion of women who were breast cancer aware from 6%, to 21% (OR 8.1, 95% CI 2.7 25) when assessed two years later using a validated questionnaire.…”

“…promoting earlier presentation of potential cancer symptoms [3][4][5][6][7] ; the use of new technologies in the assessment of pigmented skin lesions 8 ; the use of computerized decision-support tools in the diagnosis of cancer in primary care 9 ; cancer-specific education for general practitioners (GPs) 5,10 ; direct access to low-dose CT for the early detection of lung cancer in primary care 11 ; and lower symptom thresholds for urgent use of chest radiography 12 . Thus far, no trial has included a sufficiently large cohort to address the issue of whether or not expedited cancer diagnosis in primary care is beneficial, in terms of either mortality or morbidity.…”