Click to Enlarge: Distribution of Earliest Identified Cancer-Related Diagnostic Signal by Medical Record Review Among All Missed Opportunities in Cancer DiagnosisAbbreviations: CT, computed tomography; Geisinger, Geisinger Health System; VA, Department of Veterans Affairs health system.
a. Diagnostic signals listed as “Other” included pain, weight loss, and bowel changes that were not listed on the standardized data-collection instrument. See the eAppendix in Supplement 1 for full definitions of diagnostic signals (eg, cough). Source: JAMA Network Open
HOUSTON — Missed and delayed cancer diagnoses can lead to devastating outcomes. A new study has taken a major step toward quantifying and addressing this issue by developing a digital quality measure to track advanced-stage cancer diagnoses—a potential signal of preventable diagnostic delays.
The research team analyzed data from two large integrated health systems—the VA and Geisinger Health System—focusing on patients diagnosed between 2016 and 2020 with either non-small cell lung cancer or colorectal cancer. Both systems maintain comprehensive electronic health records (EHRs) and cancer registries, which enabled a detailed analysis of diagnostic timelines and patterns. Because both lung and colorectal cancer are more prevalent among veterans, early detection is particularly critical for the VA population.
The results were published in JAMA Internal Medicine.1
“While measurement of the problem is often the first step to solving it, there is no easily feasible and reliable method to measure the quality of cancer diagnosis,” said Hardeep Singh, MD, MPH, co-chief, Health Policy, Quality & Informatics, Center for Innovations in Quality, Effectiveness and Safety, Houston VAMC. “We wanted to create a digital quality measure of advanced-stage cancer presentations that used electronic data from multiple sources. This measure may signal patients who experienced missed opportunities in earlier cancer diagnosis.”
Singh and his colleagues identified patients with colorectal cancer or non-small cell lung cancer who had at least one primary care visit within 2 years prior to their diagnosis. They then calculated the proportion of Stage III or IV diagnoses—the digital quality measure—and conducted a detailed manual review of a random sample of 100 advanced-stage cases per cancer type and health system.
“We then reviewed a random sample of 100 advanced-stage cases per cancer type and health system and evaluated the medical record for diagnostic missed opportunities and diagnostic process breakdowns,” Singh said.
Among lung cancer patients, the study found, 45.9% at the VA and 58.3% at Geisinger were diagnosed at an advanced stage. Of these, 58.9% and 77.8%, respectively, had at least one missed opportunity for an earlier diagnosis. For colorectal cancer, 33.2% at the VA and 36.2% at Geisinger were diagnosed at an advanced stage, with missed opportunities occurring in 66.3% and 69.7% of cases. The median diagnostic delays—measured from the time of an initial “diagnostic signal” to completion of the workup—ranged from 1 to 20 months.
The Missed Signals
The study also identified specific “red flag” symptoms and test results that were frequently overlooked before a cancer diagnosis.
“In patients with lung cancer, the top two diagnostic signals that were missed were imaging findings and cough. In patients with colorectal cancer, the top two diagnostic signals were iron deficiency anemia and symptoms of blood in stool,” Singh told U.S. Medicine.
Screening was another major gap. According to the analysis, guideline-directed cancer screening was lacking for 16.7% and 16.2% of advanced-stage lung cancers at VA and Geisinger, respectively, and for 11.6% and 6.1% of advanced-stage colorectal cancers.
For colorectal cancer cases, patient-related factors also played a key role in delays.
“The most common factors associated with missed opportunities included patient-related factors, such as hesitancy to undergo invasive tests or access and affordability issues,” Singh said. “We also found instances of missed appointments.”
The study did have limitations, the authors noted, including the strict cutoff dates used for defining delays (seven days to initiate assessment, 30 or 60 days to complete), the overlap with the COVID-19 pandemic and possible undercounting of community-provider timelines. Even so, it provides a clear view of where missed opportunities occur and how they might be addressed.
A Blueprint for System-Level Change
“We found opportunities in both systems, and now that we have created a blueprint for a quality measure that could be useful for others, we would recommend additional evaluation and implementation at multiple health systems,” Singh said. “We believe that other health systems could use this digital quality measure to identify care gaps, develop interventions, and monitor improvements over time in response to initiatives to reduce preventable delays in cancer diagnosis.”
The VA has already implemented several initiatives since the study period, including a national precision oncology program, an early detection low-dose CT lung cancer screening program for veterans with a significant smoking history, and expanded tele-oncology services for rural areas, Singh said. These efforts could be tracked and refined using the new measure.
By developing and applying a scalable digital quality measure, the study provides a framework for identifying where delays happen, why they happen, and how they can be prevented. “System-level interventions to improve diagnostic performance could be enabled by better measurement and tracking,” he said.
- Zimolzak AJ, Kapadia P, Upadhyay DK, Korukonda S, et all. Frequent Missed Opportunities for Earlier Diagnosis of Advanced-Stage Colorectal or Lung Cancer. JAMA Intern Med. 2025 Jul 21:e252875. doi: 10.1001/jamainternmed.2025.2875. Epub ahead of print. PMID: 40690229; PMCID: PMC12281389.
