Factors affecting diagnostic timeliness and safety in symptomatic patients subsequently diagnosed with bladder and kidney cancer. A Systematic Review

Problem

Timely diagnosis of cancer is important for good clinical outcomes and patient experience. Bladder and kidney cancer, being two relatively common cancers, can pose diagnostic challenges. Symptoms such as haematuria and urinary tract infections in some patients have a higher than 3% positive predictive value for cancer, a threshold above which English GPs are advised to consider the referral of patients for, under the 2015 NICE guidelines. However, the majority of patients with these symptoms will end up not having cancer. Therefore, the decision to perform further investigations or refer patients with these common urinary symptoms may differ despite the existence of guidelines. Studying in whom, and why, some patients may experience a longer than average time to diagnosis is important to understanding how avoidable diagnostic delay can be reduced, so that targeted interventions to improve early diagnosis can be developed to improve, ultimately, the outcome of these cancers. A systematic review was therefore performed to identify the factors that affect the diagnostic timeliness and safety of patients with urological symptoms that may be suggestive of kidney and bladder cancer.

Approach

We searched Embase and Medline (Ovid) between 2000 and January 2018, for publications on symptoms/conditions including haematuria and urinary tract infection. We focused on clinical features that are listed in the 2015 NICE guidelines for suspected cancer in order to examine the population that are most likely to have cancer, and in whom a timely diagnosis is the most crucial for outcomes. We also included symptoms that might be suggestive of a UTI (including dysuria, urinary frequency, urgency, incontinence and nocturia) in order to be over-inclusive in our search.

Findings

Our initial search identified 7787 articles. Following title and abstract screening, 37 full-texts were assessed for eligibility. A final 24 relevant studies were included.Our preliminary findings include evidence on patient, clinician and system factors contributing to diagnostic timeliness and safety issues (such as completeness of evaluation/investigations and referrals) in patients with possible urological cancer. These include patient sociodemographic factors (age, gender, ethnicity), clinician type (generalist, urologist vs gynaecologist) and experience, and system factors such as delay in specialist appointment scheduling and patient no-shows.

Consequences

Our findings will provide a granular understanding of the factors contributing to avoidable diagnostic delay of patients with possible urological cancers. This is particularly important so that targeted interventions can be developed to help general practitioners to better identify and manage at-risk patients with symptoms, so as to improve early diagnosis and outcomes of urological cancers.