Georgios Lyratzopoulos

Pre-existing conditions may influence emergency cancer diagnosis risk and decisions on investigations for potential cancer symptoms. In this retrospective cohort study we investigated whether the duration of pre-existing Anxiety/Depression and chronic analgesic use was associated with emergency lung cancer diagnosis and pre-diagnostic chest-imaging activity. We used linked primary care, hospital records and cancer registration data in patients with lung cancer. Pre-existing Anxiety/Depression and chronic analgesic use were categorised as recent-onset (first recorded 12months and <72months pre-diagnosis). Multivariable logistic regression explored associations between duration of Anxiety/Depression or chronic analgesic use and i) lung cancer diagnosis following Emergency Presentation (EP), and ii) use of Chest X-Ray/CT 1–6months pre-diagnosis. Among 6650 lung cancer patients, 26% had anxiety/depression (9% recent-onset) and 39% chronic analgesic use (28% recent-onset). Long-term and recent-onset chronic analgesic use were associated with reduced odds of EP (OR = 0.26; 95%CI 0.20, 0.33 and OR = 0.60; 95%CI 0.52, 0.70, respectively) versus no analgesic use. Pre-existing Anxiety/Depression were not associated with EP. Long-term chronic analgesic use was associated with increased odds of chest-imaging 1–6months pre-diagnosis (OR = 1.33; 95%CI 1.11, 1.60), versus no analgesic use. No associations were found for imaging use with recent-onset analgesics nor Anxiety/Depression. Long-term analgesic use for painful conditions was associated with lower odds of EP and higher odds of pre-diagnostic chest-imaging. This is consistent with a possible surveillance effect, whereby long-term conditions offer opportunities for diagnosing cancer before it becomes a medical emergency. Paying attention to symptomatic patients with no long-term treatment for painful conditions and ensuring appropriate follow up may help to expedite cancer diagnosis and avoid EP.

Background: In England, people from marginalised groups are more likely to be diagnosed with, and treated for, late-stage breast cancer. Differences in routes to diagnosis, time to diagnosis and time to treatment may be contributing factors. Methods: Data from the Clinical Practice Research Datalink and the Cancer Registration Tumour and Treatment datasets were assessed for 86,564 adults diagnosed between 01 January 2009 and 31 December 2018. Associations between patient characteristics and route to diagnosis, time to diagnosis and time to treatment were examined using logistic regression and accelerated failure time models. Results: People of Asian (aOR: 0.87, CI 0.79, 0.97), Black (aOR: 0.71, CI 0.62, 0.82), or Mixed ethnicity (aOR: 0.67, CI 0.51, 0.88), those experiencing deprivation (aOR: 0.89, CI 0.85, 0.95), and those with severe mental illness (aOR: 0.87, CI 0.78, 0.98) were less likely to be diagnosed via screening. Conversely, these groups were more likely to be diagnosed via urgent suspected cancer referral and/or emergency presentation. Time to diagnosis was longer for people with a learning disability (aTR: 1.18, CI 1.06, 1.32), while time to treatment was longer for people with a learning disability (1.08, CI 1.03, 1.13), people with severe mental illness (aTR: 1.07, CI 1.04, 1.09) and people of Black (aTR: 1.10, CI 1.07, 1.13) or Other ethnicity (aTR: 1.06 CI 1.03, 1.10). Conclusions: This study provides insights into which patient groups experience inequalities in routes to diagnosis, time to diagnosis and time to treatment. The findings can be used to target strategies to reduce inequalities in stage at diagnosis and treatment.

Background: Early cancer detection is aided by timely GP referrals. However, GP practices face pressures, particularly in deprived areas, which may be associated with diagnostic inequalities. Aim: To examine whether practice-level indicators of access, workforce, and population income deprivation were associated with diagnostic care indicators. Design and setting: Retrospective longitudinal study of 6,194 practices between 2015-2019 and 2022-2023. Method: Panel fixed-effects regression examined USC referral rates, USC PPV, USC sensitivity, and emergency presentation rates. Predictors were patient-reported access, GP workforce, and practice population income deprivation. Results: Per one SD increase within practices, (i) USC referral rates were lower with better appointment-making experience (-1.4%) and older average GP age (-3.5%), and higher with female GP share (+1.3%); GP FTE showed a small positive association (+0.7% to +0.8%). (ii) USC PPV increased with older average GP age (+2.2%). (iii) USC sensitivity was lower with older average GP age (-1.1%); emergency presentations showed limited association with access or workforce factors. Practices had higher emergency presentation rates when serving the most deprived rather than least deprived populations (+13.7%). There was little evidence that deprivation modified access and workforce associations. Average GP age was an exception: USC referral associations weakened from Q2 to Q5, USC PPV peaked at Q3, and USC sensitivity was significant in the most deprived quintile. Conclusion: Practice-level access and workforce factors were associated with USC referral activity. Persistent deprivation gaps in emergency presentation suggest value in monitoring practice-level USC referrals alongside their PPV and sensitivity, and practice-level burden of emergency presentations. How this fits in: USC referral rates vary widely between general practices, and previous studies link this variation to GP age, staffing, access, practice size, QOF achievement, and deprivation (1–3). Most evidence is cross-sectional, so it is unclear whether these factors explain stable differences between practices or changes within the same practice over time. We showed that access and workforce factors were associated mainly with referral volume, while deprivation was more strongly linked to practice-level burden of emergency presentation than to practice-level referral activity. Persistent deprivation gaps in emergency presentations, despite narrowing referral-rate gaps, suggest that equity efforts should look beyond referral volume alone.

Background: In patients with cancer, diagnosis through or soon after the use of emergency hospital care (‘emergency diagnosis’) is associated with advanced disease and poor prognosis. The varied and complex reasons for emergency diagnoses—including rapid disease progression, patient factors, and system delays—are unlikely to be unique to cancer. However, little is known about the frequency and prognostic outcomes of emergency diagnosis in other conditions. We aimed to document the frequency of emergency diagnoses across various non-neoplastic conditions and examine the association of emergency diagnosis with clinical outcomes. Methods and findings: We analysed records from linked primary care, secondary care, and death data (Clinical Practice Research Datalink (CPRD), Hospital Episode Statistics, Office for National Statistics) for 1,701,154 patients with one of 13 exemplar conditions (axial spondyloarthritis, coeliac disease, coronary/ischaemic heart disease, chronic obstructive pulmonary disease (COPD), inflammatory bowel disease (IBD), Lyme disease, multiple sclerosis (MS), Parkinson’s disease, polycystic ovary syndrome, rheumatoid arthritis, schizophrenia, subacute bacterial endocarditis, and tuberculosis) in England between 1999 and 2019. We examined the percentage of patients diagnosed as an emergency and compared their mortality and time in hospital in the year post-diagnosis with patients who were not diagnosed as an emergency. Emergency diagnosis occurred in at least 20% of patients for 9 out of 13 conditions in our sample, including more than 30% of patients with Parkinson’s disease and 35% of patients with COPD. For 9 out of 13 conditions, there was a substantial increase (at least +10% difference) in 1-year mortality in patients diagnosed as an emergency versus patients who were not diagnosed as an emergency. After adjusting for age and year of diagnosis, deprivation, comorbidity burden, and the healthcare setting in which the diagnosis was made, patients diagnosed as an emergency were typically much more likely to die within one year. This association held even in conditions with generally good prognosis, such as coeliac disease (adjusted odds ratio 7.53, 95% CI [5.64, 10.1], women) and IBD (adjusted odds ratio 5.99, 95% CI [5.30, 6.78], men). Similarly large differences were observed for time in hospital in the year post-diagnosis by emergency diagnosis status. For example, adjusted rate ratios of 8.76 (95% CI [6.52, 11.8]) for men with coeliac disease, and 5.59 (95%CI [2.57, 12.2]) for women diagnosed with Lyme disease. The findings were consistent across two subsets of CPRD data (Aurum, GOLD). Analyses of patients with five supplementary cancer sites (brain, colon, lung, pancreas, and ovary) produced findings concordant with prior literature, supporting the validity of the study methods. The main study limitation is the assumption of accurate recording of diagnoses in health records. Conclusions: Emergency diagnosis is common and associated with worse clinical outcomes in a wide range of conditions with diverse aetiology. Further research and investment to reduce the number of emergency diagnoses is needed, particularly for diseases where diagnosis in community settings should be expected (e.g., rheumatoid arthritis and COPD), and conditions such as coeliac disease, IBD, and MS, where emergency diagnosis is associated with particularly poor outcomes.

Background: Emergency presentation (EP) for cancer diagnosis is associated with higher mortality, but prior research has focused largely on select cancer types or non-US populations. We estimated EP prevalence and associated mortality across 16 cancers in a national Medicare cohort. Methods: Using SEER-Medicare data, we identified patients with 16 high-burden cancers diagnosed from 2008 to 2017. EP was defined by an emergency department (ED) claim within 30 days before the index cancer claim and subtyped as inpatient EP (emergency hospitalization) or outpatient EP (after ED discharge). We estimated survival probabilities and mortality risk ratios (RRs) adjusted for demographics, tumor characteristics, comorbidity, frailty, and health-care utilization. Results: Among 929 378 patients, 28% were EPs (22% inpatient, 6% outpatient). EP prevalence ranged from 40% (liver, lung, stomach, colon, ovarian, pancreatic cancers). One-year survival was 81% for non-EPs, 60% for outpatient EPs, and 36% for inpatient EPs. Compared with non-EPs, inpatient EPs had nearly 4-fold higher 30-day adjusted mortality (RR = 3.88, 95% CI = 3.81 to 3.96), ranging from 2.1 (pancreas) to 6.3 (lymphoma). Among 90-day survivors, inpatient EPs had 51% higher 1-year mortality (RR = 1.51, 95% CI = 1.49 to 1.52), ranging from 1.1 (pancreas) to 2.1 (lymphoma). Outpatient EPs showed intermediate risk (1-year mortality RR = 1.28, 95% CI = 1.26 to 1.30). Conclusion: EP is common and predicts persistently elevated mortality in older US adults after comprehensive covariate adjustment. Associations were strongest for cancer types underrepresented in prior research, including hematological malignancies and breast, prostate, and bladder cancers. Routine EP monitoring could improve risk stratification at diagnosis and guide efforts to reduce avoidable emergency presentations.

Preclinical cancer sojourn time—defined here as the duration a cancer is undetected but detectable—is important for understanding disease progression and evaluating screening policies. This study aims to robustly characterise empirical evidence and existing knowledge over mean sojourn times across 21 stageable tumour sites, including stage-specific preclinical cancer sojourn times and the sojourn time of circulating tumour DNA (ctDNA)-positive cancers. We updated an existing literature review through to February 2025 to extract population-level empirical sojourn time estimates derived from mathematical models of primary screening data. To synthesise this heterogeneous literature, quantify uncertainty, and obtain estimates for cancer-sites lacking empirical evidence, we conducted a formal Structured Expert Elicitation involving 15 clinical experts. The elicitation was grounded on the literature review results, supplemented by an evidence dossier that included survival data and outcomes from relevant ctDNA cancer studies. The literature review revealed heterogeneity in existing literature, which focused on a small subset of screened cancers (e.g., breast, cervical, colorectal). The elicitation successfully generated comprehensive probability distributions of overall mean sojourn times for all 21 cancer-sites (representing the site of tumour origin), as well as stage-specific sojourn times and overall sojourn times for ctDNA-positive cancers across 14 cancer-sites. This study used robust methodology to quantitatively describe existing evidence and experts’ beliefs on the sojourn time of multiple cancer-sites, also describing uncertainty. Such estimates are important for future evaluations of the clinical impact, potential for overdiagnosis and subsequent cost-effectiveness of emerging screening technologies, including multi-cancer detection tests.

Structured electronic health records (EHRs) are increasingly being used to predict risk of disease by analysing ‘patient trajectories’. We conducted a PubMed and Web of Science search for studies using temporal EHR sequences to identify disease signatures or predict disease. This scoping review assesses study characteristics, identifies model types, and appraises performance and reporting.

Objectives Body mass index (BMI) confers a higher risk of colorectal cancer (CRC) and may influence cancer diagnostic pathways. We investigated variations in diagnostic pathways by BMI category among patients with symptomatic CRC. Design Retrospective cohort study using linked cancer registry, primary, and secondary care data. Setting England Participants 5571 patients with symptomatic CRC diagnosed in England between 2011 and 2015. Primary and secondary outcome measures Route to CRC diagnosis (emergency presentation and fast-track referrals among patients with new-onset red flag symptoms), presenting symptoms and pre-diagnostic endoscopy use. Results Red-flag symptoms (change in bowel habit, rectal bleeding) were more frequently recorded among patients with rectal cancer with obesity and overweight versus normal weight (65.2% and 65.5% vs 56.8%, respectively). Among colon cancer patients endoscopy during the year pre-diagnosis was used in a greater proportion of patients with obesity versus normal weight (72.8% vs 64.4%, pConclusions Patients with CRC with higher BMI are more likely to be referred urgently and less likely to experience emergency cancer diagnosis than normal weight patients.

Migrants are often diagnosed with cancer at more advanced stages than the background population, resulting in poorer prognosis. The route to cancer diagnos