Published online Jun 28, 2023. doi: 10.3748/wjg.v29.i24.3825
Peer-review started: March 20, 2023
First decision: April 27, 2023
Revised: May 5, 2023
Accepted: May 25, 2023
Article in press: May 25, 2023
Published online: June 28, 2023
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 via 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 via 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 via an ‘other’ or Unknown route. The proportion diagnosed via 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 via 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.
Core Tip: We investigated changes to routes to diagnosis for cholangiocarcinoma patients across England’s 21 regional Cancer Alliances over a 12-year period, and factors associated with differences. We found almost half (49.6%) of 23632 patients in the study were diagnosed via emergency presentation, a route associated with late presentation, advanced disease and poorer outcomes. Those diagnosed by Two Week Wait referral through a primary care doctor, where earlier diagnoses are possible, increased from 9.8-19.8% from 2006-2017, still considered low. Significant regional variation was found, alongside the discovery that age, comorbidities and underlying liver disease had independent associations with their routes to diagnosis.