Impact of comorbidity and healthcare utilization on colorectal cancer stage at diagnosis: literature review

Abstract

Purpose-Individuals diagnosed with cancer close to death have low access to enrollment in palliative care programs. The purpose of this literature review was to assess the usefulness of prediagnostic comorbidity and healthcare utilization as indicators of late-stage colorectal cancer (CRC) diagnosis, to help with early identification of individuals who may benefit from palliative care.Methods-A literature search was conducted in relevant databases using title/abstract terms which included "cancer," "stage," "diagnosis," "determinants," "predictors," and "associated." Included studies examined whether comorbidity and/or healthcare utilization had an impact on the CIHR Author ManuscriptCIHR Author Manuscript CIHR Author Manuscript stage at which CRC was diagnosed. A standardized data abstraction form was used to assess the eligibility of each study. Thirteen articles were included in the literature review. These studies were assessed and synthesized using qualitative methodology.Results-We found much heterogeneity among study variables. The findings of this literature review point to the presence of comorbidity and non-emergent healthcare utilization as having no association with late-stage diagnosis. Conversely, emergency room presentation (ERP) was associated with late-stage diagnosis.Conclusions-The results of this literature review did not find strong evidence to suggest that comorbidity and healthcare utilization are potential indicators of late-stage diagnosis. However, ERP may be useful as a flag for consideration of prompt referral to palliative care. Additional research is required to identify potential indicators of late-stage diagnosis that may be available in administrative databases, particularly in the area of healthcare utilization.

The impact of comorbidity on cancer and its treatment

“…Comorbidity may result in increased contact with health services resulting in more opportunities for screening and early diagnosis; or, conversely, comorbidity may distract either or both the patient and the health professional, resulting in delayed diagnosis . How these two mechanisms play out varies by cancer and comorbidity type, with studies in different populations reporting that, depending on the context, those with comorbidity may have their cancer diagnosed at an earlier, later, or at a similar stage as those without comorbidity .…”

Comorbid chronic diseases and cancer diagnosis: disease-specific effects and underlying mechanisms

“…Herein, we focus on the influence of chronic conditions on the diagnostic process and their impact on two prognostically important diagnostic outcomes: stage at diagnosis, and emergency presentation status. Motivated by the limitations in current evidence [9][10][11][12] , we also examine whether the impact varies for specific chronic diseases and cancer types. To elucidate mechanisms through which chronic diseases may influence the diagnosis of cancer, we review the evidence on diseasespecific effects on various process measures that characterise the diagnostic pathway: participation in cancer screening; patients' help-seeking for cancer symptoms; clinicians' decision-making regarding use of investigations; and time from symptom onset to diagnosis.…”

“…Particularly relevant when symptoms of cancer and of the chronic condition overlap. 12,22,28,86 COPD and lung cancer IBS and colon/ovarian cancer ACE-inhibitor induced cough and lung cancer…”

“…By integrating the available evidence, we developed a comprehensive framework of the likely mechanisms through which chronic diseases can interfere with or facilitate timely cancer diagnosis influencing participation in cancer screening, help-seeking for cancer symptoms, diagnostic strategies and use of investigations ( Figure 2). Novel mechanisms of influence have emerged (Box 2), which integrate previously hypothesised theories, including the 'alternative explanations', 'competing demands', 'surveillance effect' 12,22,28,86 and 'pathological hypothesis 22,100 23 . Communication difficulties and worries of appearing hypochondriac may also interfere with reporting of cancer symptoms in patients with mental health problems 51,73 .…”

Patterns of health care utilization preceding a colorectal cancer diagnosis are strong predictors of dying quickly following diagnosis

“…Specifically, identifying factors prior to diagnosis that are predictive of dying quickly after a cancer diagnosis may help with early identification of persons who would benefit from early formal palliative care services and perhaps should be targeted for a PCP consultation upon diagnosis. Patient demographics, co-morbidities, and health care utilization prior to diagnosis may be helpful in this regard as they represent potential indicators or “flags” that can be assessed in an efficient manner and at a population-level due to their availability in large administrative databases [ 14 ]. These factors also align with the ‘groups’ of predictors classified by Walshe et al [ 13 ] in relation to access to palliative care services.…”