Diagnostic flow for all patients referred with non-specific symptoms of cancer to a diagnostic centre in Denmark: A descriptive study.

European Journal of General Practice 2024, VOL. 30, NO. 1, 2296108 https://doi.org/10.1080/13814788.2023.2296108 RESEARCH ARTICLE Diagnostic flow for all patients referred with non-specific symptoms of cancer to a diagnostic centre in Denmark: A descriptive study Christina Sadolin Damhusa,b , John Brandt Brodersena,b,c and Gunnar Lauge Nielsend,e The Centre of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark; bThe Research Unit for General Practice in Region Zealand, Denmark; cDepartment of Community Medicine, General Practice Research Unit, Faculty of Health Sciences, UiT, The Arctic University of Norway, Tromsø, Norway; dDepartment of Internal Medicine, Aalborg University Hospital, Aalborg, Denmark; eDepartment of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark a KEY MESSAGES •• Eight percent of NSSC-CPP referrals yielded cancer diagnoses, with two additional cancers diagnosed in a 6-month follow-up. •• Over one-fourth of referrals to NSSC-CPP were redirected to other departments or general practitioners. •• This study outlines the diagnostic flow for all NSSC-CPP-referred patients, offering unique insights crucial for comparing European diagnostic practices. ABSTRACT Background: Since 2012, Cancer Patient Pathways for Non-specific Symptoms and Signs of Cancer (NSSC-CPP) have been implemented in Scandinavia and UK. Objectives: This study aimed to describe the diagnostic flow for all patients referred from 1 January to 30 June 2020 to the NSSC-CPP in the Diagnostic Centre in Farsø (DC-F), Denmark. Methods: During the study period, we prospectively recorded information on the diagnostic flow, including: pathway trajectory, symptoms and findings leading to referral, diagnostic procedures and diagnoses at the end of DC Farsø work-up and within 6-months for all patients referred to the NSSC-CPP in DC Farsø using electronic patient files and the Danish National Patient Registry (DNPR). Results: Of the 314 referrals to DC Farsø, 227 had diagnostic work-up in DC Farsø, the remaining were redirected to other CPPs (n = 11), outpatient clinics (n = 45) or redirected to general practice (n = 25). Of total referrals, 25 (8%) received a malignant diagnosis, 20 (6%) a non-malignant but clinically relevant diagnosis with initiation of treatment, 16 (5%) a non-malignant diagnosis but no treatment needed and in 253 (81%) referrals no severe new condition was diagnosed. Two (1%) additional malignancies were diagnosed within a 6-month follow-up period. Conclusion: By tracking all patients referred to the NSSC-CPP in DC Farsø, including those redirected, this is the first study to describe the diagnostic flow for all patients referred to a diagnostic centre in Denmark. This knowledge is important for further organisation and planning of the NSSC-CPP. Introduction Early diagnosis of cancer is a priority of governments in the Global North, which in the United Kingdom (UK) led to the implementation of two-week wait referrals (2WW) to support general practitioners (GPs) in fast detection of cancer [1]. Similarly, Cancer Patient Pathways (CPPs) or clinical guidelines to expedite the investigation, diagnosis, and treatment of symptomatic individuals have been introduced in Norway [2], CONTACT Christina Sadolin Damhus Copenhagen, Denmark ARTICLE HISTORY Received 13 January 2023 Revised 11 December 2023 Accepted 12 December 2023 KEYWORDS Non-specific symptoms; diagnostic centre; cancer patient pathway; diagnoses Sweden [3], United Kingdom [4], Spain and New Zealand [5,6]. In Denmark, since 2007, patients with alarm symptoms of cancer can be referred to an Organ Specific Cancer Patient Pathway (OS-CCP), which is a standardised fast-track pathway established for 31 suspected cancer types [7]. However, more than half of patients with cancer present with vague or non-specific symptoms, such as unexplained weight loss, fatigue or anaemia, which do not qualify for an OS-CPP [8]. The Centre of General Practice, Department of Public Health, University of Copenhagen, © 2024 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The terms on which this article has been published allow the posting of the Accepted Manuscript in a repository by the author(s) or with their consent. 2 C. S. DAMHUS ET AL. Consequently, in 2012, an additional CPP for non-specific symptoms and signs of cancer (NSSC-CPP), also referred to as the ‘diagnostic pathway,’ was implemented in Denmark and in 2015 copied to Norway and Sweden (Box 1) [2,3, 9]. Likewise, with inspiration from Denmark, UK, introduced in 2017 NSSC-CPPs, in different versions to reflect local healthcare systems and clinical priorities [10–15]. As far as we are aware, no studies have followed the trajectory of a consecutive cohort of patients first referred to the NSSC-CPP irrespective the setting in which the following work-up was carried out. This information is essential to document quality in the diagnostic centre’s decisions and assess the outcomes in patients referred to these centres. Therefore, this study aimed to describe the diagnostic flow, including pathway trajectory, symptoms and findings leading to referral, diagnostic procedures, diagnoses at the end of DC work-up and new malignant diagnoses within a six-month follow-up period for all patients referred from 1 January to 30 June 2020 to the NSSC-CPP in the Diagnostic Centre in Farsø (DC Farsø), Denmark. Box 1. The Cancer Patient Pathway for Non-specific Symptoms and Signs of Cancer (NSSC-CPP) in Denmark: Setting, Guidelines and Practice In the Danish healthcare system, general practitioners (GP) are gatekeepers to the secondary healthcare system and the CPPs and NSSC-CPPs are most often initiated by GPs [1]. The first mandatory step of the NSSC-CPP includes anamnesis, objective examination and a pre-specified blood panel. If deemed necessary diagnostic images as X-ray, ultrasound or CT scan may be added after this initial work-up. According to national guidelines, GPs can take this second step themselves or send patients directly to the hospital departments responsible for NSSC-CPP [2]. These departments, often referred to as diagnostic centres (DC), are responsible for all diagnostic steps, such as further diagnostic work-up or redirection of the patient [2]. Twenty-one diagnostic centres are implemented across the five health regions in Denmark where regional and intra-regional differences regarding organisational and clinical practice have been demonstrated in the diagnostic centres [4–6]. About 10% of patients referred to the NSSC-CPP in Denmark are diagnosed with cancer after completed workups and the remaining 90 (...truncated)