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This study aimed to identify colorectal cancer (CRC) diagnostic pathways and describe patients in those pathway groups.This was a cross-sectional study of CRC patients in Ontario, Canada, diagnosed 2009-2012 that used linked administrative data at ICES. We used cluster analysis on 11 pathway variables characterising patient presentation, symptoms, procedures and referrals. We assessed associations between patient- and disease-related characteristics and diagnostic pathway group. We further characterised the pathways by diagnostic interval and number of related physician visits.Six diagnostic pathways were identified, with three adhering to provincial diagnostic guidelines: screening (N = 4494), colonoscopy (N = 10,066) and imaging plus colonoscopy (N = 3427). Non-adherent pathways were imaging alone (N = 2238), imaging and emergency presentation (N = 2849) and no pre-diagnostic workup (N = 887). Patients in adherent pathways were younger, had fewer comorbidities, lived in less deprived areas and had earlier stage disease. The median diagnostic interval length varied across pathways from 12 to 126 days, correlating with the number of CRC-related visits.This study demonstrated substantial variations in real-world CRC diagnostic pathways and 25% were diagnosed through non-adherent pathways. Those patients were older, had more comorbid disease and had higher stage cancer. Further research needs to identify and describe the reasons for divergent diagnostic processes.

Introduction Colorectal cancer (CRC) is the third most common cancer worldwide (Ferlay et al., 2015, International Journal of Cancer, 136, E359), and delayed diagnosis is associated with mortality (Torring et al., 2011, British Journal of Cancer, 104, 934; Torring et al., 2012, Journal of Clinical Epidemiology, 65, 669). The purpose of this review was to determine the factors associated with time to diagnosis in symptomatic CRC using scoping review methods. Methods We performed database and citation searches to identify studies which examine the length of any interval from symptom presentation to diagnosis. Study selection was conducted by two independent reviewers. Factors contributing to time to diagnosis were extracted from selected articles and mapped onto a conceptual framework consisting of four levels: patient and disease factors, provider factors, organisation/setting factors and sectors of influence. Results From the 31 studies included in this review, we identified 138 unique factors, 17 of which were investigated by at least three studies and 11 of which had consistent results. Patient and disease factors were most commonly studied. Patient perception that their symptoms were benign, a non-urgent referral, female sex and rectal tumour location were each associated with a longer time to diagnosis. Conclusion Thus far, the literature has focused on patient or disease-related factors, while other levels of influence have been relatively understudied.

BACKGROUND Colonoscopy is a key resource used to diagnose colorectal cancer (CRC). This study evaluated the relationship between colonoscopy availability and the length of the CRC diagnostic interval. METHODS This is a cross-sectional study of CRC patients diagnosed in Ontario, Canada, in 2008-2012. We used administrative health data to characterise colonoscopist density, private colonoscopy clinic access, distance to the closest colonoscopist and the diagnostic interval, defined as the time from patients' first cancer-related healthcare encounter to their cancer diagnosis date. We used multivariable quantile regression to evaluate the association between colonoscopy availability and the diagnostic interval, modelling the median and 90th percentile. RESULTS The median diagnostic interval was 84 days (90th percentile 323 days). The diagnostic interval was longer in patients residing in areas with lower colonoscopists density or private clinic access (adjusted median difference = 9 and 19 days, respectively), with evidence of effect modification by symptom status. Increased distance to a colonoscopist was associated with a longer diagnostic interval in asymptomatic patients, but a shorter diagnostic interval in symptomatic patients (adjusted median difference = 29 and -25 days, respectively). CONCLUSIONS This study demonstrated that reduced colonoscopy resource availability is associated with longer diagnostic intervals for CRC patients.

Delayed diagnosis of breast cancer can adversely impact patient outcomes. To better understand this issue, we conducted a scoping review of literature from 1996 to 2015 that examined predictors of delayed presentation and diagnosis among women with breast cancer symptoms. We performed searches to identify studies of predictors of the time from symptom onset to first presentation (the patient interval), first presentation to diagnosis (the diagnostic interval) and symptom onset to diagnosis (the total interval) among women with breast cancer symptoms. Two reviewers independently reviewed and abstracted the findings of these studies. Of the 22 studies included in this review, 16 examined predictors of the patient interval, six examined predictors of the diagnostic interval and four examined predictors of the total interval. A total of 116 predictors were examined; three had evidence of an association with a less timely diagnosis: not disclosing symptoms to others, non-lump breast symptoms and African American ethnicity. Improving awareness of atypical breast cancer symptoms and encouraging disclosure could improve the timeliness of a breast cancer diagnosis. Access concerns for vulnerable groups need to be addressed. Future research should be more purposeful in its choice of predictors, possibly through the use of established conceptual frameworks.

The length of the cancer diagnostic interval can affect a patient's survival and psychosocial well-being. Ontario Diagnostic Assessment Units (DAUs) were designed to expedite the diagnostic process through coordinated care. We examined the effect of DAUs on the diagnostic interval among female patients with symptomatic breast cancer in Ontario using the Ontario Cancer Registry linked to administrative healthcare data. The diagnostic interval was defined as the time from patients' first referral or test to the cancer diagnosis. DAU use was determined based on the hospital where the breast biopsy/surgery was performed. Multivariable quantile regression and logistic regression analyses adjusted for possible confounders. Forty-seven per cent of patients were diagnosed in a DAU and 53% in usual care (UC). DAUs achieved the Canadian timeliness targets more often than UC (71.7% vs. 58.1%, respectively). DAU use was associated with a 10-day (95% CI: 7.8-11.9) reduction in the median diagnostic interval. This effect increased to 19 days for patients at the 75th percentile and 22 days for those at the 90th percentile of the diagnostic interval distribution. Use of an Ontario DAU is associated with a shorter time to diagnosis in patients with symptomatic breast cancer, especially for those who would otherwise wait the longest.

Research suggests that social support can have an impact on health-related quality of life (HRQOL). Social support can be structural support (SSS) or functional support (FSS). Our study was designed to clarify the relationships between HRQOL, FSS and SSS. We conducted a cross-sectional survey and a detailed chart review. The study population was men attending a follow-up clinic after receiving radiotherapy for prostate cancer. Functional social support was measured by using the MOS Social Support Survey. Structural social support was measured by using questions adapted from the 1994-1995 National Population Health Survey conducted by Statistics Canada. Health-related quality of life was measured by using the European Organization for Research and Treatment of Cancer's QLQ-C30. We found a statistically significant positive correlation between FSS and HRQOL but no association between overall SSS and HRQOL. Worsening urinary symptoms were significantly associated with lower levels of FSS and with lower HRQOL. This study underscores that the perception of support (functional) is more important than the amount or size of support (structural). We also identified a subgroup of men who have lower FSS and lower HRQOL that suffer from urinary side effects of their treatment. Further research to clarify the relationship between FSS and urinary symptoms will also clarify how an intervention could improve the HRQOL of these men.