Prolonged Diagnostic Intervals as Marker of Missed Diagnostic Opportunities in Bladder and Kidney Cancer Patients with Alarm Features: A Longitudinal Linked Data Study

Abstract

Background: In England, patients who meet National Institute for Health and Care Excellence (NICE) guideline criteria for suspected cancer should receive a specialist assessment within 14 days. We examined how quickly bladder and kidney cancer patients who met fast-track referral criteria were actually diagnosed. Methods: We used linked primary care and cancer registration data on bladder and kidney cancer patients who met fast-track referral criteria and examined the time from their first presentation with alarm features to diagnosis. Using logistic regression we examined factors most likely to be associated with non-timely diagnosis (defined as intervals exceeding 90 days), adjusting for age, sex and cancer type, positing that such occurrences represent missed opportunity for timely referral, possibly due to sub-optimal guideline adherence. Results: 28%, 42% and 31% of all urological cancer patients reported no, one or two or more relevant symptoms respectively in the year before diagnosis. Of the 2105 patients with alarm features warranting fast-track assessment, 1373 (65%) presented with unexplained haematuria, 382 (18%) with recurrent urinary tract infections (UTIs), 303 (14%) with visible haematuria, and 45 (2%) with an abdominal mass. 27% overall, and 24%, 45%, 18% and 27% of each group respectively, had a non-timely diagnosis. Presentation with recurrent UTI was associated with longest median diagnostic interval (median 83 days, IQR 43–151) and visible haematuria with the shortest (median 50 days, IQR 30–79). After adjustment, presentation with recurrent UTIs, being in the youngest or oldest age group, female sex, and diagnosis of kidney and upper tract urothelial cancer, were associated with greater odds of non-timely diagnosis. Conclusion: More than a quarter of patients presenting with fast-track referral features did not achieve a timely diagnosis, suggesting inadequate guideline adherence for some patients. The findings highlight a substantial number of opportunities for expediting the diagnosis of patients with bladder or kidney cancers.

Identifying opportunities for timely diagnosis of bladder and renal cancer via abnormal blood tests: a longitudinal linked data study

“…Details of data acquisition and cohort identification have been described in previous studies. 17 , 29 Data on patients aged ≥25 years who were diagnosed with bladder and renal cancer between April 2012 and December 2015 were extracted from the CPRD. These data were linked at source to the cancer registry, from which additional patients were identified using International Classification of Diseases, Tenth Revision (ICD-10) cancer codes.…”

“… 17 , 25 , 28 Each patient’s index abnormal test was defined as the first abnormal test within the 12-month period before diagnosis, concordant with prior literature. 17 , 29 …”

Risk prediction models for symptomatic patients with bladder and kidney cancer: a systematic review

“…A prolonged primary care interval (from patient presentation to referral) is associated with worse clinical outcomes [4,5]. Currently, in England, median diagnosis time for bladder and kidney cancer -after presentation in primary care with a relevant clinical feature -is 51 and 70 days respectively, with variation seen by symptom [6]. Visible haematuria is present in the majority of patients with bladder cancer (53%), however, it is less common in individuals diagnosed with kidney cancer (18%) [7].…”

“…While 5.1% of people with VH in a primary care setting are ultimately diagnosed with urological cancers, the positive predictive value (PPV) of NVH is less certain and may be as low as 1.6% in primary care [7]. The focus on haematuria may impede early identification of cancers that present atypically or with a number of non-specific symptoms [6,9]. This could also lead to the over-referral of lower risk individuals presenting with haematuria [10].…”

The Direct Semi-Quantitative Detection of 18 Pathogens and Simultaneous Screening for Nine Resistance Genes in Clinical Urine Samples by a High-Throughput Multiplex Genetic Detection System

“…Globally, this condition affects approximately 150 million people each year, resulting in approximately 3.5 billion dollars in health costs (Dıáz et al, 2020). Furthermore, UTIs can cause serious sequelae, including frequent recurrences, pyelonephritis with sepsis, renal damage in young children, pre-term birth in pregnant women, and complications caused by the frequent use of antimicrobial drugs, including high-level antibiotic resistance (Flores-Mireles et al, 2015;Karavanaki et al, 2019;Rousham et al, 2019;Zhou et al, 2021). Previous research has shown that the focus of infection in 20-30% of all patients with sepsis is localized in the urogenital tract and that urosepsis may cause mortality rates of 25% to 60% in certain patient groups (Wagenlehner et al, 2008).…”