1. Cancer Diagnosis in the Acute Setting (CaDiAS)
Cathy Hughes1, Negin Sarafraz-Shekary2, Aradhna Kaushal2, Amanda Ramirez2, Tim Benepal3,
Christopher Watts4, Lindsay Forbes2 and Thomas Newsom-Davis1
1Chelsea & Westminster Hospital, London, UK; 2King’s College London, UK; 3St George’s Hospital, London, UK; 4York Medical Practice, Twickenham , UK
Aims
Study Design
Progress
CaDiAS involves the study of patients with a new diagnosis of lung (and colorectal) cancer who present as an emergency. It aims to:
understand the whole diagnostic pathway, from first recognising a symptom to emergency presentation in secondary care, including the role of primary care
map the patient, clinical and organisational factors that contribute to an emergency new cancer diagnosis
suggest ways to improve outcomes by identifying gaps in service provision and opportunities to diagnosis cancer earlier
CaDiAS started recruiting in March 2013, and all sites were open by July 2013.
The six sites are: Chelsea & Westminster Hospital, Croydon Hospital, Guy’s & St Thomas’ Hospital, Hillingdon Hospital, Lewisham Hospital and St George’s Hospital.
As of 18th October 2013, 71 patients had been recruited.
Of the 42 patients not recruited, 15 (36%) were too unwell and 8 (15%) died before consent could be obtained. Eight patients (15%) declined to participate.
Of the 71 patients recruited, 48 (68%) had lung cancer. Of these:
Sixty percent were male
The median age was 71.5 years (range 44 to 99 years)
An analysis of the quality of data collection from 34 patient interviews was carried out in October 2013:
Overall the interviews were conducted in an appropriately structured and empathic manner
There were three examples of mild distress by patients, all to do with trying to remember details
Two relatives became upset during the interview
Data completeness was good, however the duration of trigger symptoms was only recorded in 89% of interviews, the duration of symptoms was only noted in 88%, and the nature of the first symptoms in 93% of patients
Inclusion Criteria
Age > 18 years
AND
New diagnosis of lung (including mesothelioma) or colorectal cancer
Cancer diagnosis made during an inpatient admission which followed presentation via ED, an acute assessment unit, or an acute medical unit, whether self-referred to ED, GP-referred as an emergency on the same day or admitted from outpatients clinic on the same day.
Patients in whom cancer is diagnosed incidentally during an emergency admission for an apparently unrelated medical problem should be included. OR
Cancer diagnosis made in outpatients that led from an emergency attendance with no inpatient admission or an emergency admission.
Status in Recruitment Process
Total
Consented 71
Waiting consent 26
Patients not recruited 42
Total Patients Identified
139
Conclusions
Background
Findings so far confirm the feasibility of conducting a study investigating primary care, secondary care and patient views on the factors associated with emergency cancer diagnoses.
This is a very unwell population of patients and a significant proportion die quickly or are too unwell to take part in the study. For those who do participate, a sensitive and skilled researcher is needed.
Few patients declined to participate. Of those that did take part, the patient interview caused little distress to the patient and only very occasional upset to patients’ relatives.
Data collection continues and is due to complete in Summer 2014.
Data is collected from three sources:
Primary care data includes a significant event analysis to understand the patient’s route to diagnosis from the primary care point of view
A semi-structured patient interview schedule identifies the pathway to diagnosis in the months leading up to the admission
There are six participating hospitals in London. It is hoped that about 250 of the estimated 386 eligible patients will participate over a one year period.
In England, 25% of all newly diagnosed cancer patients present as an emergency1. This is more likely in some tumour types (lung cancer, 39%), in older people, and in those from more deprived backgrounds. The relative one-year survival is significantly lower, suggesting that the disease is more advanced at diagnosis1.
Little is known about the reasons why so many cancer patients present acutely with a potentially delayed diagnosis. Addressing the factors responsible and identifying opportunities to diagnose cancer earlier is key to improving outcomes.
Previous work has been limited by separating primary and secondary care2, whilst data on the patient experience is limited. CaDiAS is uniquely designed to examine all aspects of the diagnostic journey and consider improvements in practice across all three domains.
Acknowledgements
We thank the investigators of each site: Mr Muti Abulafi, Dr Amy Guppy, Dr Lena Karapanagiotu, Dr Sarah Ngan, Dr Daniel Smith and Dr Anna-Mary Young.
This work is funded by NHS England and London Cancer Alliance.
Contact Information
Dr Thomas Newsom-Davis
Chelsea & Westminster Hospital
369 Fulham Road, London SW10 9NH
1National Cancer Intelligence Network (2010) Routes to Diagnosis- NCIN Data Briefing. National Cancer Intelligence Network, London.
2Royal College of General Practitioners (2011) National Audit of Cancer Diagnosis in Primary Care.