Linda Aagaard Rasmussen

In recent decades, advances in early detection and treatment have improved breast cancer (BC) survival [1]. Due to increasing incidence and 5-year survival rates exceeding 90% in high-income countr...

Background: GPs may detect cancer recurrence (CR) between specialised follow-up visits or after completed follow-up. Knowledge of CR detection is needed to inform GP decision making in general practice. Aim: To examine how often GPs suspected cancer in patients presenting with CR, diagnostic actions taken, and how cancer suspicion and diagnostic actions were associated with the time to recurrence diagnosis. Design and setting: A retrospective cohort study was conducted linking survey data and national register data. Method: Patients diagnosed with recurrence (of one of seven cancer types) between 1 January 2022 and 31 May 2024 were included. Their GPs provided details on the diagnostic process. Results: The GP survey response rate was 48% (1265/2611), and 469 patients presented with signs or symptoms of recurrence. The GPs suspected cancer at the first consultation in 226 patients (48%). A referral was made for diagnostic evaluation in 282 (60%) patients, with fast-track cancer pathways being the most frequent (48%) and fastest referral mode. Diagnostic intervals differed across cancer types at the 90th percentile. The longest intervals were seen for melanoma recurrence, which was 47 days longer than colorectal CR. The median diagnostic interval was 60 days shorter when GPs suspected cancer compared with no suspicion of cancer or other serious disease. Conclusion: The GPs suspected cancer in approximately half of the patients and referred three in five presenting with signs or symptoms of recurrence. In approximately one-third, the GP had no suspicion. The length of the diagnostic interval differed considerably between the seven investigated cancer types.

Background: GPs may detect cancer recurrences between specialised visits or after completed follow-up. There is limited evidence on diagnostic routes to detecting cancer recurrence. Aim: To examine the level of GP involvement in cancer recurrence detection and to assess the time from the index consultation in general practice to a cancer recurrence diagnosis (diagnostic interval). Design and setting: This was a retrospective cohort study linking survey data from 667 Danish general practices with national register data. Method: Patients with a recurrence of seven cancer types diagnosed between 1 January 2022 and 31 May 2024 were included. The patients’ GPs provided details on how the recurrence was detected. Results: The GP survey achieved a response rate of 1265/2611 (48%). Of 1081 patients with recurrence, 478 (44%) first presented signs or symptoms of recurrence in general practice. Recurrence was diagnosed in 758 patients (70%) while they were under active specialised follow-up, and in 291 patients (27%) after completion of follow-up. Of 352 patients with a symptomatic presentation in general practice, the diagnostic pathway was initiated in general practice in 243 (69%), during subsequent follow-up in 57 (16%), and via other routes in 52 (15%). For patients with general practice-initiated diagnostic pathways, the 50th and 90th percentile of the diagnostic interval was 48 and 251 days for symptomatic presentations and 23 and 125 days for asymptomatic presentations, respectively. Conclusion: Four in 10 patients with cancer recurrence had their first point of contact in general practice. However, significant delays were observed. Improving detection pathways for cancer recurrence in general practice may benefit survivors across cancer types.

The objective was to investigate how patient characteristics, clinical characteristics and prognosis were associated with lymphoma diagnoses in unplanned pathways. We included 7,157 consecutive patients diagnosed with lymphoma in a nationwide register-based study in Denmark. An unplanned pathway was defined as an acute admission within 30 days before diagnosis and compared to all other pathways combined. A total of 21% of patients were diagnosed in unplanned pathways, varying from 13% in indolent non-Hodgkin lymphoma to 32% in aggressive non-Hodgkin lymphoma. The probability of being diagnosed in an unplanned pathway was higher for patients with comorbidity, B-symptoms, abnormal blood test results, advanced disease stage and poor performance score (PS) at diagnosis. Diagnosis in an unplanned pathway was associated with higher mortality, for example, HR 2.03 (95% CI:1.74-2.38 for PS 0). Increased disease severity at diagnosis was associated with unplanned diagnostic pathways. Diagnosis in an unplanned pathway was associated with higher mortality.

Irreversible tissue damage is frequently present at the time of diagnosis in systemic sclerosis (SSc), which calls for earlier diagnosis. This study estimated healthcare utilization three years before the diagnosis of SSc. We conducted a population-based cohort study using data from Danish national registries. Incident patients diagnosed with SSc between January 1, 2005, and December 31, 2018, were matched by age and gender with 10 references without SSc. The date of diagnosis was the index date. We estimated quarterly rates and adjusted incidence rate ratios (IRRs) with 95% confidence intervals (CI) of healthcare utilization in the three years preceding the diagnosis for patients with SSc and their references. A total of 1,650 SSc patients (1,255 women and 395 men) and 16 500 non-SSc references were included. The mean age was 58 years (interquartile range 48–68). Three years before diagnosis, patients with SSc had more contacts with general practice (IRR_women= 1.43 [95% CI: 1.33; 1.53], IRR_men= 1.47 [95% CI: 1.26; 1.71]) and hospitals (IRR_women= 1.86 [95% CI: 1.62; 2.14], IRR_men= 2.70 [95% CI: 2.04; 3.58]) compared with their references. In the last three months before diagnosis, patients with SSc had significantly more contacts with general practice (IRR_women= 2.30 [95% CI: 2.16; 2.44], IRR_men= 2.98 [95% CI: 2.64; 3.35]) and hospitals (IRR_women= 5.62 [95% CI: 5.08; 6.20], IRR_men= 9.53 [95% CI: 7.81; 11.63]). The higher use of healthcare services in general practice and hospitals in the three years before diagnosis suggests an opportunity to facilitate earlier diagnosis and treatment of SSc.

Multiple myeloma often presents with vague and non-specific symptoms. Many patients are diagnosed in unplanned rather than elective (planned) diagnostic pathways. This study investigates the diagnosis of multiple myeloma in unplanned pathways and the association with patient characteristics, disease profile, and survival. We conducted a nationwide register-based study, including all patients diagnosed with multiple myeloma in Denmark in 2014–2018. Patients were categorised as diagnosed in an unplanned pathway if registered with an acute admission within 30 days prior to the multiple myeloma diagnosis and no other previously registered pathway to this diagnosis. Unplanned pathways were compared to all other pathways combined. We included 2,213 patients diagnosed with multiple myeloma, hereof 32% diagnosed in an unplanned pathway. Comorbidity, no prior cancer diagnosis, a history of few visits to the general practitioner (GP), multiple myeloma complications at diagnosis, high-risk cytogenetics, and advanced cancer stage were associated with a higher probability of being diagnosed in an unplanned pathway. For example, 24.4% (95% confidence interval (CI): 21.8–27.0) of patients with low comorbidity (Charlson Comorbidity Index (CCI) score 0) were diagnosed in an unplanned pathway as were 50.9% (95% CI: 45.6–56.1) of patients with high comorbidity (CCI score 3+). For patients with dialysis need at the time of diagnosis the probability was 66.0% (95% CI 54.2–77.8) and 30.9% (95% CI: 28.9–32.9) for patients with no dialysis need. Patients diagnosed in an unplanned pathway had inferior survival (hazard ratio 1.44 (95% CI: 1.26–1.64)). However, this association was not seen in analyses restricted to patients surviving for more than three years. High comorbidity level, few usual GP visits, advanced disease status at diagnosis, and complications were associated with diagnosis in an unplanned pathway. Further, patients diagnosed in an unplanned pathway had inferior survival. Promoting earlier diagnosis and preventing unplanned pathways may help improve survival in multiple myeloma.

Purpose To investigate the association between fear of cancer recurrence (FCR) and healthcare use in general practice among cancer survivors. Methods We linked nationwide register data to survey data on FCR in cancer survivors at 2.5 years after a cancer diagnosis. Multiple regression models were used to analyse the association between high FCR level and quartiles of healthcare use at 18–30 months before the cancer diagnosis (habitual healthcare use) and between high FCR level and healthcare use at 18–30 months after the cancer diagnosis (survivorship healthcare use). Results We included 1538 cancer survivors in the study. High habitual healthcare use was associated with a high level of FCR (odds ratio = 2.07 (95% confidence interval (CI): 1.36–3.15)) for the 4th quartile of healthcare use compared to the 1st quartile. A high FCR score was also associated with higher healthcare use during cancer survivorship (incidence rate ratio (IRR) = 1.26 (95% CI: 1.14–1.40)). This association remained statistically significant when adjusting for habitual healthcare use (IRR = 1.20 (95% CI: 1.09–1.33)). Conclusion High healthcare use before the cancer diagnosis was associated with high FCR during survivorship. This indicates that FCR is partly explained by a general (pre-diagnostic) health concern. High FCR predicted high healthcare use during cancer survivorship, even when adjusting for habitual healthcare use. Implications for Cancer Survivors Our results suggest that FCR in cancer survivors is triggered by a general high level of health concern, and the cancer diagnosis may further exacerbate this concern.

Background: Patients with multimorbidity are frequent users of healthcare, but fragmented care may lead to suboptimal treatment. Yet, this has never been examined across healthcare sectors on a national scale. We aimed to quantify care fragmentation using various measures and to analyze the associations with patient outcomes. Methods: We conducted a register-based nationwide cohort study with 4.7 million Danish adult citizens. All healthcare contacts to primary care and hospitals during 2018 were recorded. Clinical fragmentation indicators included number of healthcare contacts, involved providers, provider transitions, and hospital trajectories. Formal fragmentation indices assessed care concentration, dispersion, and contact sequence. The patient outcomes were potentially inappropriate medication and all-cause mortality adjusted for demographics, socioeconomic factors, and morbidity level. Results: The number of involved healthcare providers, provider transitions, and hospital trajectories rose with increasing morbidity levels. Patients with 3 versus 6 conditions had a mean of 4.0 versus 6.9 involved providers and 6.6 versus 13.7 provider transitions. The proportion of contacts to the patient’s own general practice remained stable across morbidity levels. High levels of care fragmentation were associated with higher rates of potentially inappropriate medication and increased mortality on all fragmentation measures after adjusting for demographic characteristics, socioeconomic factors, and morbidity. The strongest associations with potentially inappropriate medication and mortality were found for ≥ 20 contacts versus none (incidence rate ratio 2.83, 95% CI 2.77–2.90) and ≥ 20 hospital trajectories versus none (hazard ratio 10.8, 95% CI 9.48–12.4), respectively. Having less than 25% of contacts with your usual provider was associated with an incidence rate ratio of potentially inappropriate medication of 1.49 (95% CI 1.40–1.58) and a mortality hazard ratio of 2.59 (95% CI 2.36–2.84) compared with full continuity. For the associations between fragmentation measures and patient outcomes, there were no clear interactions with number of conditions. Conclusions: Several clinical indicators of care fragmentation were associated with morbidity level. Care fragmentation was associated with higher rates of potentially inappropriate medication and increased mortality even when adjusting for the most important confounders. Frequent contact to the usual provider, fewer transitions, and better coordination were associated with better patient outcomes regardless of morbidity level.