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Epidemiology
Original research
Time intervals and routes to diagnosis for lung cancer in 10 jurisdictions: cross-sectional study findings from the International Cancer Benchmarking Partnership (ICBP)
  1. Usha Menon1,
  2. Peter Vedsted2,
  3. Alina Zalounina Falborg2,
  4. Henry Jensen2,
  5. Samantha Harrison3,
  6. Irene Reguilon3,
  7. Andriana Barisic4,
  8. Rebecca J Bergin5,6,
  9. David H Brewster7,8,
  10. John Butler9,
  11. Odd Terje Brustugun10,
  12. Oliver Bucher11,
  13. Victoria Cairnduff12,
  14. Anna Gavin12,
  15. Eva Grunfeld13,
  16. Elizabeth Harland11,
  17. Jatinderpal Kalsi1,
  18. Anne Kari Knudsen14,15,
  19. Mats Lambe16,17,
  20. Rebecca-Jane Law18,
  21. Yulan Lin14,15,
  22. Martin Malmberg19,
  23. Donna Turner20,
  24. Richard D Neal18,21,
  25. Victoria White5,22,
  26. David Weller7
  1. 1 Institute for Women’s Health, University College London, London, UK
  2. 2 Research Unit for General Practice, Aarhus University, Aarhus, Denmark
  3. 3 Policy and Information, Cancer Research UK, London, UK
  4. 4 Department of Prevention and Cancer Control, Cancer Care Ontario, Toronto, Ontario, Canada
  5. 5 Centre for Behavioural Research in Cancer, Cancer Council Victoria, Melbourne, Victoria, Australia
  6. 6 Department of General Practice, University of Melbourne, Melbourne, Victoria, Australia
  7. 7 Centre for Population Health Sciences, Edinburgh University, Edinburgh, UK
  8. 8 Scottish Cancer Registry, Information Services Division, NHS National Services Scotland, Edinburgh, UK
  9. 9 The Royal Marsden, London, UK
  10. 10 Institute for Cancer Research, Olso University Hospital, Oslo, Norway
  11. 11 Department of Epidemiology and Cancer Registry, CancerCare Manitoba, Winnipeg, Manitoba, Canada
  12. 12 Northern Ireland Cancer Registry, Queen’s University Belfast, Belfast, UK
  13. 13 Health Services Research Program, Ontario Institute for Cancer Research, Toronto, Ontario, Canada
  14. 14 European Palliative Care Research Centre (PRC), Olso University Hospital, Oslo, Norway
  15. 15 Institute of Clinical Medicine, University of Oslo, Oslo, Norway
  16. 16 Department of Medical Epidemiology, Karolinska Institutet, Stockholm, Sweden
  17. 17 Regional Oncologic Center, University Hospital, Uppsala, Sweden
  18. 18 North Wales Centre for Primary Care Research, Bangor University, Wrexham, UK
  19. 19 Department of Oncology, Lund University Hospital, Lund, Sweden
  20. 20 Population Oncology, CancerCare Manitoba, Winnipeg, Manitoba, Canada
  21. 21 Academic Unit of Primary Care, University of Leeds, Leeds, UK
  22. 22 School of Psychology, Deakin University, Geelong, Victoria, Australia
  1. Correspondence to Professor Usha Menon; u.menon{at}ucl.ac.uk

Abstract

Objective Differences in time intervals to diagnosis and treatment between jurisdictions may contribute to previously reported differences in stage at diagnosis and survival. The International Cancer Benchmarking Partnership Module 4 reports the first international comparison of routes to diagnosis and time intervals from symptom onset until treatment start for patients with lung cancer.

Design Newly diagnosed patients with lung cancer, their primary care physicians (PCPs) and cancer treatment specialists (CTSs) were surveyed in Victoria (Australia), Manitoba and Ontario (Canada), Northern Ireland, England, Scotland and Wales (UK), Denmark, Norway and Sweden. Using Wales as the reference jurisdiction, the 50th, 75th and 90th percentiles for intervals were compared using quantile regression adjusted for age, gender and comorbidity.

Participants Consecutive newly diagnosed patients with lung cancer, aged ≥40 years, diagnosed between October 2012 and March 2015 were identified through cancer registries. Of 10 203 eligible symptomatic patients contacted, 2631 (27.5%) responded and 2143 (21.0%) were included in the analysis. Data were also available from 1211 (56.6%) of their PCPs and 643 (37.0%) of their CTS.

Primary and secondary outcome measures Interval lengths (days; primary), routes to diagnosis and symptoms (secondary).

Results With the exception of Denmark (−49 days), in all other jurisdictions, the median adjusted total interval from symptom onset to treatment, for respondents diagnosed in 2012–2015, was similar to that of Wales (116 days). Denmark had shorter median adjusted primary care interval (−11 days) than Wales (20 days); Sweden had shorter (−20) and Manitoba longer (+40) median adjusted diagnostic intervals compared with Wales (45 days). Denmark (−13), Manitoba (−11), England (−9) and Northern Ireland (−4) had shorter median adjusted treatment intervals than Wales (43 days). The differences were greater for the 10% of patients who waited the longest. Based on overall trends, jurisdictions could be grouped into those with trends of reduced, longer and similar intervals to Wales. The proportion of patients diagnosed following presentation to the PCP ranged from 35% to 75%.

Conclusion There are differences between jurisdictions in interval to treatment, which are magnified in patients with lung cancer who wait the longest. The data could help jurisdictions develop more focused lung cancer policy and targeted clinical initiatives. Future analysis will explore if these differences in intervals impact on stage or survival.

  • lung cancer
  • routes to diagnosis
  • time intervals
  • international health systems
  • symptomatic presentation

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.

https://doi.org/10.1136/bmjopen-2018-025895

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    Footnotes

    • UM, PV and DW contributed equally.

    • Collaborators ICBP Module 4 Working Group: Alina Zalounina Falborg (Research Unit for General Practice, Department of Public Health, Aarhus University), Andriana Barisic (Department of Prevention and Cancer Control, Cancer Care Ontario), Anna Gavin (Northern Ireland Cancer Registry, Centre for Public Health, Queen’s University Belfast), Anne Kari Knudsen (European Palliative Care Research Centre (PRC), Department of Oncology, Oslo University Hospital and Institute of Clinical Medicine), Breann Hawryluk (Department of Patient Navigation, Cancer Care Manitoba), Chantelle Anandan (Centre for Population Health Sciences, University of Edinburgh), Conan Donnelly (Centre for Public Health, Queen’s University Belfast), David H Brewster, Scottish Cancer Registry, Information Services Division, NHS National Services Scotland, David Weller (Centre for Population Health Sciences, University of Edinburgh), Donna Turner (Population Oncology, Cancer Care Manitoba), Elizabeth Harland (Department of Epidemiology and Cancer Registry, CancerCare Manitoba), Eva Grunfeld (Knowledge Translation Research Network Health Services Research Program, Ontario Institute for Cancer Research; Professor and Vice Chair Research Department of Family and Community Medicine, University of Toronto), Evangelia Ourania Fourkala (Gynaecological Cancer Research Centre, Women’s Cancer, Institute for Women’s Health, University College London), Henry Jensen (Research Unit for General Practice, Department of Public Health, Aarhus University), Irene Reguilon (International Cancer Benchmarking Partnership, Cancer Research UK), Jackie Boylan (Centre for Public Health, Queen’s University Belfast), Jacqueline Kelly (Northern Ireland Cancer Registry, Centre for Public Health, Queen’s University Belfast), Jatinderpal Kalsi (Gynaecological Cancer Research Centre, Women’s Cancer, Institute for Women’s Health, University College London), John Butler (The Royal Marsden) Kerry Moore, Centre for Public Health, Queen's University Belfast, Martin Malmberg (Department of Oncology, Lund University Hospital), Mats Lambe (Regional Cancer Center Uppsala and Department of Medical Epidemiology and Biostatics, Karolinska Institutet), Oliver Bucher (Department of Epidemiology and Cancer Registry, CancerCare Manitoba), Peter Vedsted, Research Unit for General Practice, Department of Public Health, Aarhus University, Rebecca-Jane Law (North Wales Centre for Primary Care Research, Bangor University), Rebecca Bergin (Centre for Behavioural Research in Cancer; Department of General Practice, University of Melbourne), Richard D Neal (North Wales Centre for Primary Care Research, Bangor University; Academic Unit of Primary Care, Leeds Institute of Health Sciences, University of Leeds), Samantha Harrison, Early Diagnosis and International Cancer Benchmarking Partnership, Policy and Information, Cancer Research UK, Sigrun Saur Almberg (Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Therese Kearney (Northern Ireland Cancer Registry, Centre for Public Health, Queen’s University Belfast), Victoria Cairnduff (Northern Ireland Cancer Registry, Centre for Public Health, Queen’s University Belfast), Victoria Hammersley (Centre for Population Health Sciences, University of Edinburgh), Victoria White (Centre for Behavioural Research in Cancer, Cancer Council Victoria Road; School of Psychology Deakin University), Usha Menon (Gynaecological Cancer Research Centre, Women’s Cancer, Institute for Women's Health, University College London), Yulan Lin (European Palliative Care Research Centre (PRC), Department of Oncology, Oslo University Hospital and Institute of Clinical Medicine). ICBP Programme Board: Aileen Keel (Scottish Government, Edinburgh, Scotland); Anna Boltong (Cancer Council Victoria, Carlton, Australia); Anna Gavin (Northern Ireland Cancer Registry, Queen’s University, Belfast, UK); David Currow (Cancer Institute New South Wales, Sydney, Australia); Gareth Davies (Wales Cancer Network, Cardiff, UK); Gunilla Gunnarsson (Swedish Association of Local Authorities and Regions, Stockholm, Sweden); Heather Bryant (Canadian Partnership Against Cancer, Toronto, Canada); Jane Hanson (Welsh Cancer National Specialist Advisory Group, Cardiff, UK); Kathryn Whitfield (Department of Health, Victoria Australia); Linda Rabeneck (Cancer Care Ontario, Toronto, Canada); Michael A Richards (Care Quality Commission, London, UK); Michael Sherar (Cancer Care Ontario, Toronto, Canada); Nicola Quin (Cancer Council Victoria, Carlton, Australia); Nicole Mittmann (Cancer Care Ontario, Toronto, Canada); Robert Thomas (Department of Health and Human Services, Victoria, Melbourne, Australia); Sara Hiom (Cancer Research UK); Sean Duffy (NHS England, London, UK); Chris Harrison (NHS England, London, UK); Søren Brostrøm (Danish Health and Medicines Authority, Copenhagen, Denmark); and Stein Kaasa (University Hospital of Trondheim, Trondheim, Norway). ICBP Academic Reference Group: Professor Jan Willem Coebergh, Professor of Cancer Surveillance, Department of Public Health, Erasmus Universiteit Rotterdam, Rotterdam, the Netherlands; Jon Emery, Professor of Primary Care Cancer Research, University of Melbourne and Clinical Professor of General Practice, University of Western Australia, Australia; Dr Stefan Bergström, senior consultant oncologist, Department of Oncology, Gävle, Sweden; Dr Monique E van Leerdam, Erasmus MC University Medical Centre, the Netherlands; Professor Marie-Louise Essink-Bot, Academic Medical Centre, Amsterdam University, the Netherlands; Professor Una MacLeod, Senior Lecturer in General Practice and Primary Care, Hull-York Medical School, UK.

    • Contributors UM, DW, PV, AZF and HJ planned the study design, data collection, carried out the analyses and wrote the draft manuscript. UM, PV, DW, HJ, AB, AKK, RJB, DHB, JK, VC, AG, EG, EH, ML, RJL, YL, MM, DT, RDN, VW, IR and SH were responsible for local data collection (alongside the Working Group), management and interpretation and have participated in writing and have approving the final manuscript version. JB, OB and OTB provided advice on the interpretation of results in their respective jurisdictions and comments or substantial edits on the manuscript and approving the final version.

    • Funding This work was supported by: CancerCare Manitoba; Cancer Care Ontario; Canadian Partnership Against Cancer; Cancer Council Victoria; Cancer Research Wales; Cancer Research UK; Danish Cancer Society; Danish Health and Medicines Authority; European Palliative Care Research Centre; Norwegian University of Science and Technology; Northern Ireland Guidelines Audit and Implementation Network; Macmillan Cancer Support; National Cancer Action Team; National Health Service (NHS) England; Medical Research Council (MR_UU_12023), Northern Ireland Cancer Registry, funded by the Public Health Agency Northern Ireland; Norwegian Directorate of Health; Research Centre for Cancer Diagnosis in Primary Care, Aarhus University, Denmark; Scottish Government; Swedish Association of Local Authorities and Regions; University College London and NIHR Biomedical Research Centre at University College London NHS Foundation Trust; University of Edinburgh; Victorian Department of Health and Human Services; and Welsh Government.

    • Disclaimer The funding bodies had no influence on the design of the study and collection, analysis and interpretation of data, in writing the manuscript or whether to publish the results.

    • Competing interests None declared.

    • Patient consent for publication Obtained.

    • Ethics approval For each local data collection, there were specific procedures and approvals that included anonymised data transfer to University College London and Aarhus University. Approvals were received from the following institutions: Cancer Council Victoria Human Research Ethics Committee (HREC 112); Health Research Ethics Board, University of Manitoba (HS15227 (H2012:105)); Research Resource Ethics Committee, CancerCare Manitoba (RRIC#28-2012); University of Toronto Research Ethics Board (27881); The Danish Data Protection Agency (2013-41-2030); Swedish Ethics Review Board, Uppsala (2013/306); Norway Regional committees for medical and health research ethics (2013/136/REK nord); England, Wales and Scotland, NRES Committee East Midlands – Derby 2, local R&D for each health board (11/EM/0420); and Northern Ireland ORECNI Ethical approval, local governance for each health Trust (11/EM/0420).

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data availability statement The data that support the findings of this study are available from the named authors from each ICBP jurisdictions but restrictions apply to the availability of these data and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of the ICBP Programme Board. Please contact the ICBP Programme Management team, based at Cancer Research UK, with any queries (icbp@cancer.org.uk).