Department of Analytics, Health Data Insight CIC, Cambridge CB21 5XE, United Kingdom.
National Disease Registration Service, NHS England, London E14 4PU, United Kingdom.
World J Gastroenterol. 2023 Jun 28;29(24):3825-3842. doi: 10.3748/wjg.v29.i24.3825.
Incidence of cholangiocarcinoma (CCA) is rising, with overall prognosis re-maining very poor. Reasons for the high mortality of CCA include its late presentation in most patients, when curative options are no longer feasible, and poor response to systemic therapies for advanced disease. Late presentation presents a large barrier to improving outcomes and is often associated with diagnosis mergency presentation (EP). Earlier diagnoses may be made by Two Week Wait (TWW) referrals through General practitioner (GP). We hypothesise that TWW referrals and EP routes to diagnosis differ across regions in England.
To investigate routes to diagnosis of CCA over time, regional variation and influencing factors.
We linked patient records from the National Cancer Registration Dataset to Hospital Episode Statistics, Cancer Waiting Times and Cancer Screening Programme datasets to define routes to diagnosis and certain patient characteristics for patients diagnosed 2006-2017 in England. We used linear probability models to investigate geographic variation by assessing the proportions of patients diagnosed TWW referral or EP across Cancer Alliances in England, adjusting for potential confounders. Correlation between the proportion of people diagnosed by TWW referral and EP was investigated with Spearman's correlation coefficient.
Of 23632 patients diagnosed between 2006-2017 in England, the most common route to diagnosis was EP (49.6%). Non-TWW GP referrals accounted for 20.5% of diagnosis routes, 13.8% were diagnosed by TWW referral, and the remainder 16.2% were diagnosed an 'other' or Unknown route. The proportion diagnosed a TWW referral doubled between 2006-2017 rising from 9.9% to 19.8%, conversely EP diagnosis route declined, falling from 51.3% to 46.0%. Statistically significant variation in both the TWW referral and EP proportions was found across Cancer Alliances. Age, presence of comorbidity and underlying liver disease were independently associated with both a lower proportion of patients diagnosed TWW referral, and a higher proportion diagnosed by EP after adjusting for other potential confounders.
There is significant geographic and socio-demographic variation in routes to diagnosis of CCA in England. Knowledge sharing of best practice may improve diagnostic pathways and reduce unwarranted variation.
胆管癌（CCA）的发病率正在上升，整体预后仍然很差。CCA 死亡率高的原因包括大多数患者就诊时已处于晚期，此时已无法进行根治性治疗，以及晚期疾病的系统治疗反应不佳。就诊时间晚是改善预后的一大障碍，且常与紧急就诊（EP）相关。通过全科医生（GP）的两周就诊（TWW）转诊，可能更早诊断出该病。我们假设 TWW 转诊和 EP 诊断途径在英格兰不同地区存在差异。
研究 CCA 的诊断途径随时间的变化、区域差异及其影响因素。
我们将国家癌症登记数据集的患者记录与医院住院统计、癌症等待时间和癌症筛查计划数据集相链接，以确定 2006-2017 年在英格兰诊断出 CCA 的患者的诊断途径和某些患者特征。我们使用线性概率模型通过评估英格兰各癌症联盟中通过 TWW 转诊或 EP 诊断的患者比例来评估地理差异，同时调整潜在混杂因素。使用 Spearman 相关系数来研究通过 TWW 转诊和 EP 诊断的患者比例之间的相关性。
在英格兰 2006-2017 年期间诊断出的 23632 例患者中，最常见的诊断途径是 EP（49.6%）。非 TWW 的 GP 转诊占诊断途径的 20.5%，13.8%通过 TWW 转诊诊断，其余 16.2%通过“其他”或未知途径诊断。2006-2017 年期间，通过 TWW 转诊诊断的患者比例增加了一倍，从 9.9%增加到 19.8%，相反 EP 诊断途径的比例下降，从 51.3%下降到 46.0%。在癌症联盟之间，TWW 转诊和 EP 比例均存在统计学显著差异。年龄、合并症和潜在肝脏疾病与通过 TWW 转诊的患者比例较低，以及 EP 诊断的患者比例较高均独立相关，且在调整其他潜在混杂因素后，结果仍然成立。
在英格兰，CCA 的诊断途径存在显著的地理和社会人口统计学差异。最佳实践知识共享可能会改善诊断途径并减少不必要的差异。
