Timely follow-up of positive cancer screening results: A systematic review and recommendations from the PROSPR Consortium

Chyke A Doubeni¹, Nicole B Gabler², Cosette M Wheeler³, Anne Marie McCarthy⁴, Philip E Castle⁵, Ethan A Halm⁶, Mitchell D Schnall⁷, Celette S Skinner⁸, Anna N A Tosteson⁹, Donald L Weaver¹⁰, Anil Vachani¹¹, Shivan J Mehta¹², Katharine A Rendle¹³, Stacey A Fedewa¹⁴, Douglas A Corley^{15

16}, Katrina Armstrong¹⁷

Affiliations

¹ Chair and The Presidential Associate Professor of Family Medicine and Community Health, Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
² Senior Research Investigator, Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
³ Professor of Pathology, Department of Pathology, and Professor of Obstetrics and Gynecology, Department of Obstetrics and Gynecology, University of New Mexico Health Science Center, Albuquerque, NM.
⁴ Assistant in Epidemiology, General Medicine Division, MA General Hospital, Harvard Medical School, Boston, MA.
⁵ Professor of Epidemiology and Population Health, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY.
⁶ Professor of Internal Medicine, Department of Internal Medicine and Professor of Clinical Sciences, Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX.
⁷ Chair and The Eugene P. Pendergrass Professor of Radiology, Department of Radiology, Breast Imaging Section, University of Pennsylvania, Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA.
⁸ Parkland Community Medicine Professor, Department of Clinical Sciences and Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX.
⁹ James J. Carroll Professor, The Dartmouth Institute for Health Policy and Clinical Practice and Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH.
¹⁰ Professor of Pathology, Department of Pathology, UVM Cancer Center, University of Vermont, Burlington, VT.
¹¹ Assistant Professor of Medicine, Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
¹² Assistant Professor of Medicine and Health Policy, Department of Medicine, Perelman School of Medicine and Penn Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA.
¹³ Assistant Professor of Family Medicine and Community Health, Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
¹⁴ Screening and Risk Factor Surveillance, Surveillance and Health Services Research, American Cancer Society, Atlanta, GA.
¹⁵ Research Scientist III, Kaiser Permanente Division of Research, Oakland, CA.
¹⁶ Clinical Professor of Medicine, San Francisco Medical, Kaiser Permanente Northern California, San Francisco, CA.
¹⁷ Physician in Chief, General Medicine Division, MA General Hospital, Harvard Medical School, Boston, MA.

PMID: 29603147
PMCID: PMC5980732
DOI: 10.3322/caac.21452

Timely follow-up of positive cancer screening results: A systematic review and recommendations from the PROSPR Consortium

Chyke A Doubeni et al. CA Cancer J Clin. 2018 May.

. 2018 May;68(3):199-216.

doi: 10.3322/caac.21452. Epub 2018 Mar 30.

Authors

Affiliations

¹ Chair and The Presidential Associate Professor of Family Medicine and Community Health, Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
² Senior Research Investigator, Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
³ Professor of Pathology, Department of Pathology, and Professor of Obstetrics and Gynecology, Department of Obstetrics and Gynecology, University of New Mexico Health Science Center, Albuquerque, NM.
⁴ Assistant in Epidemiology, General Medicine Division, MA General Hospital, Harvard Medical School, Boston, MA.
⁵ Professor of Epidemiology and Population Health, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY.
⁶ Professor of Internal Medicine, Department of Internal Medicine and Professor of Clinical Sciences, Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX.
⁷ Chair and The Eugene P. Pendergrass Professor of Radiology, Department of Radiology, Breast Imaging Section, University of Pennsylvania, Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA.
⁸ Parkland Community Medicine Professor, Department of Clinical Sciences and Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX.
⁹ James J. Carroll Professor, The Dartmouth Institute for Health Policy and Clinical Practice and Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH.
¹⁰ Professor of Pathology, Department of Pathology, UVM Cancer Center, University of Vermont, Burlington, VT.
¹¹ Assistant Professor of Medicine, Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
¹² Assistant Professor of Medicine and Health Policy, Department of Medicine, Perelman School of Medicine and Penn Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA.
¹³ Assistant Professor of Family Medicine and Community Health, Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
¹⁴ Screening and Risk Factor Surveillance, Surveillance and Health Services Research, American Cancer Society, Atlanta, GA.
¹⁵ Research Scientist III, Kaiser Permanente Division of Research, Oakland, CA.
¹⁶ Clinical Professor of Medicine, San Francisco Medical, Kaiser Permanente Northern California, San Francisco, CA.
¹⁷ Physician in Chief, General Medicine Division, MA General Hospital, Harvard Medical School, Boston, MA.

PMID: 29603147
PMCID: PMC5980732
DOI: 10.3322/caac.21452

Abstract

Timely follow-up for positive cancer screening results remains suboptimal, and the evidence base to inform decisions on optimizing the timeliness of diagnostic testing is unclear. This systematic review evaluated published studies regarding time to follow-up after a positive screening for breast, cervical, colorectal, and lung cancers. The quality of available evidence was very low or low across cancers, with potential attenuated or reversed associations from confounding by indication in most studies. Overall, evidence suggested that the risk for poorer cancer outcomes rises with longer wait times that vary within and across cancer types, which supports performing diagnostic testing as soon as feasible after the positive result, but evidence for specific time targets is limited. Within these limitations, we provide our opinion on cancer-specific recommendations for times to follow-up and how existing guidelines relate to the current evidence. Thresholds set should consider patient worry, potential for loss to follow-up with prolonged wait times, and available resources. Research is needed to better guide the timeliness of diagnostic follow-up, including considerations for patient preferences and existing barriers, while addressing methodological weaknesses. Research is also needed to identify effective interventions for reducing wait times for diagnostic testing, particularly in underserved or low-resource settings. CA Cancer J Clin 2018;68:199-216. © 2018 American Cancer Society.

Keywords: breast; cervix uteri; colon; early detection of cancer; early diagnosis; lung; mass screening; neoplasm.

PubMed Disclaimer

Conflict of interest statement

Disclaimer: No part of this study has been presented in any form and the authors have no conflicts of interest. Dr. Doubeni is a member of the US Preventive Services Task Force (USPSTF). This article does not necessarily represent the views and policies of the USPSTF.

Stacey A. Fedewa is employed by the American Cancer Society, which received a grant from Merck, Inc. for intramural research outside the submitted work; however, her salary is solely funded through American Cancer Society funds.

Figures

**Figure 1**
Analytic framework for the systematic review on time to diagnosis after positive screen. This model indicates how the timing of diagnostic testing can impact the pathways between (1) the positive screening test and cancer mortality and (2) the positive screening test and cancer diagnosis.

**Figure 2**
Study flow diagram for the selection of included studies in the systematic review

**Figure 3**
**(a) and (b)**. Association between intervals for diagnostic testing and outcomes for (a) breast cancer and (b) colorectal cancer. Abbreviations: T=tumor size; CI=confidence interval

See this image and copyright information in PMC

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Timely follow-up of positive cancer screening results: A systematic review and recommendations from the PROSPR Consortium

Affiliations

Timely follow-up of positive cancer screening results: A systematic review and recommendations from the PROSPR Consortium

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

References

Publication types

MeSH terms

Grants and funding

LinkOut - more resources

Full Text Sources

Other Literature Sources