Dr Tanimola Martins Tani Diagnosis of Symptomatic Cancer Optimally D I S C O Email tom207exeteracuk Introduction Tanimola Martins Tani Research Fellow Diagnosis of Symptomatic Cancer Optimally ID: 913385
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Slide1
Ethnic differences in diagnosis and outcomes of cancer
Dr Tanimola Martins (Tani)
Diagnosis of Symptomatic Cancer Optimally (
D
I
S
C
O)
Email:
tom207@exeter.ac.uk
Slide2Introduction
Tanimola Martins (Tani)
Research Fellow - Diagnosis of Symptomatic Cancer Optimally (
DISCO)Medical rehabilitation and Public Health
Brief background
Some key findings of previous studies
CRUK Population Research Fellowship
Slide3Background
All Cancers Excluding Non-Melanoma Skin Cancer (C00-C97 Excl. C44): 2010-2011
Age-Standardised Five-Year Net Survival, England and Wales
Slide4Progress in cancer
survival in
seven high-income countries 1995–2014 (ICBP SURVMARK-2): a population-based study
Arnold, Melina et al.The Lancet Oncology, Volume 20, Issue 11, 1493 - 1505(November 2019) Background
Slide5AgeGeneral state of healthAdvanced-stage at diagnosis
Tumour type
Treatment options
DeprivationExplaining cancer survival in the UKScreening uptakeSymptoms awareness Prolonged patient interval Prolonged primary care intervalProlonged secondary care intervalTumour typeBackground
Slide6Improving UK cancer survival
Prevent cancer
Diagnose
cancer earlier and faster Ensure the best treatment and care Improve long-term quality of lifeDevelop our expert workforceThe independent Cancer Taskforce
Slide7Ethnic inequality in cancer
Ethnic minority Vs White British
United States:
For nearly all common cancers, the incidence and mortality rates are higher among African Americans compared to other ethnic groups- poverty /health insurance status Coupland VH Lagergren J Konfortion J et al. . Ethnicity in relation to incidence of oesophageal and gastric cancer in England . Br J Cancer 2012 ; 107 : 1908 – 14 .Cuthbertson SA Goyder EC Poole J . Inequalities in breast cancer stage at diagnosis in the Trent region, and implications for the NHS Breast Screening Programme . J Public Health 2009 ; 31 : 398 – 405National Cancer Intelligence Network . Mortality From Prostate Cancer . Bristol: South West Public Health Observatory , 2012IncidenceSurvival (1 and 3 year)LungLower Higher in Asian Breast (female)Lower
Lower in Black
Colorectal
Lower
No difference
Prostate
Higher
Lower in Black
Oesophagus
Higher
Unknown
Stomach
Higher
Unknown
Cervical
Higher
Unknown
Uterus
Higher
Unknown
Myeloma
Higher
Unknown
Liver
Higher
Unknown
Mouth
Higher
Unknown
Pancreas
Lower
Unknown
Ovary
Lower
Unknown
Bladder
Lower
Unknown
Kidney
Lower
Unknown
Slide8Predictors of ethnic inequality in cancer survival
Awareness signs and symptoms
Differential uptake of screening
Tumour characteristics - worse for breast and prostateComorbidities Poverty Patient experience of care Prolonged patient interval Prolonged primary care intervalProlonged secondary care intervalWhat about…?
Slide9Explaining ethnic inequality in cancer survival: variation in diagnostic interval
Slide10Systematic review findings
Seven studies
breast, colorectal, oesophagus,
lung, prostate, NHL, and ovarianLonger patient and primary care intervals of diagnosis - breast, oesophagus and colorectal Five studies on breast Quality satisfactory Explaining ethnic inequality in cancer survival: variation in diagnostic interval
Slide11Explaining ethnic inequality in cancer survival: vignette study of patients’ preferences for
cancer testing - PIVOT studies
Slide12Explaining ethnic inequality in cancer survival: vignettes study of patients’ preferences for cancer testing - PIVOT studies
Slide13Explaining ethnic inequality in prostate cancer: differential use of primary care
Health care Use by Men with Urinary Symptoms (HUMUS) study
Survey of men with recent urinary symptoms
Lower urinary symptoms prompting help-seeking Date of symptoms onset and first presentation in primary care – patient intervalDate of offer/performance of PSA and DRE Frequency of consultation before the offer of PSA & DRE Lower urinary symptoms Hesitancy
Frequency of micturition
Nocturia
Urgency
Urgency-with-dribble
Retention
Sexual/erectile dysfunction
Haematuria
Unexplained weight loss
Unexplained fatigue or tiredness
Qualitative methods
Face-to-face interviews examined same aspects
White (n=9), Asian (n=5) and Black (n=9)
Analysis of GP records
Date of first presentation
Dates of Offer
of PSA and
DRE
Slide14Survey of 274 men:
White (n=197), Asian (n=36) and Black Men(n=41)
Experience
of lower urinary symptoms - number and typeNocturia and Erectile dysfunction - prompted help-seeking Multiple first symptoms was commonSignificant under-reporting of symptoms notably in Black men*Results
Health care Use by Men with Urinary Symptoms (HUMUS) study
Slide15No
significant
difference by ethnicity in
patient interval Offer of PSA and DRE 47% offered DRE and 55% offered PSAAsian men were significantly less likely to be offered PSA test Median patient interval - 56 days (IQR: 21-252)
Vs
7
days (95% CI: 5-8)
National Audit of Cancer
58 % presented in 90 days
14%
within 126
days
28% within
252 days
or more after noticing symptoms
Patient
interval
Frequency of consultation before the offer of PSA & DRE
Black men less likely to be offered DRE during first GP consultation
More survey results
Health care Use by Men with Urinary Symptoms (HUMUS) study
Slide16“It
was a little bit embarrassment to let him know that sometimes I wee
myself” Black_52yrs
Disclosure of symptoms during consultation“..you don't have the time to speak to the GP, you've only got 10 minutes”. Black 60yrs“She discharge her patients very quickly....” White_64yrs
Qualitative data - themes
Health care Use by Men with Urinary Symptoms (HUMUS) study
“No
, I don't know about that [PSA test
]”. Asian_70yrs
“
I don't know PSA. They asked me to go for blood tests.
They
take my blood, maybe one ml of blood or whatever, then they send it to my
GP”. Black_67
PSA test offer
Slide17Qualitative - themes
So,
she
checked and she said... well, she don’t think that I have got any problem with the prostate. It’s just that something that enlarge it, like a ball that will block it. Anyhow, that was okay so I know now, I know for a fact that it’s nothing to do with prostate. Black_75yrsGP-Patient communicationSafety nettingPatient’s approach to GP consultationHealth care Use by Men with Urinary Symptoms (HUMUS) study
Slide18A summary of the evidence so far…
Incidence
Survival (1 and 3 year)
LungLower Higher in Asian Breast (female)Lower Lower in Black Colorectal Lower No difference Prostate Higher Lower in BlackOesophagus Higher Unknown Stomach
Higher
Unknown
Cervical
Higher
Unknown
Uterus
Higher
Unknown
Myeloma
Higher
Unknown
Liver
Higher
Unknown
Mouth
Higher
Unknown
Pancreas
Lower
Unknown
Ovary
Lower
Unknown
Bladder
Lower
Unknown
Kidney
Lower
Unknown
Breast cancer
Poor awareness of symptoms
Low uptake of screening
Tumour characteristics
Longer
patient
intervals
Longer primary
care intervals
Prostat
e
cancer
Tumour characteristics
No
evidence of inequality in
symptoms awareness
No evidence of inequality in patient
intervals
No evidence of inequality in primary care
intervals
Patients’ preference for investigation
Differential offer of investigation
GP-patient communication
Safety netting
PRECISION trial: using MRI to help diagnose prostate cancer
Slide19Population Research Postdoctoral FellowshipMethodsAnalysis of electronic medical records
CPRD - Clinical Practice Research Datalink
Linked Hospital Episode statistics data
Cancer registry Office for National Statistics Ethnic inequality in cancer diagnosis and outcomes Lung, breast, colorectal, prostate, stomach, oral,
liver, ovarian
,
oesophageal
, cervical, and myeloma
Slide20Population Research Postdoctoral FellowshipA. Ethnic differences in cancer diagnosis
Consultation rates in primary care before specialist referral
Reported symptoms profile
Patient interval Primary care interval Route to diagnosis B. Ethnic differences in cancer outcomesStaging at diagnosis Survival rates
Slide21Population Research Postdoctoral Fellowship
Prof William Hamilton - UEMS
Dr Obi Ukwomune - UEMS
Dr Gary Abel - UEMSProf Yoryos Lyratzopoulos UCL
Prof
Bernard
Rachet
-
LSHTM
Prof Frank
Chinegwundoh