“Delaying diagnosis had a significant impact on the treatment eventually received by patients in our study,” said lead author Dr Raviteja Miriyala, senior resident, Department of Radiotherapy and Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India. “Patients with longer delays before diagnosis were more likely to receive palliative, rather than curative, treatment because they had advanced disease — and are likely to have poorer outcomes.”
Early diagnosis and treatment improve the outcome of most cancers. This study analysed causes of delays and the impact on treatment. A prospective audit was conducted of all 162 cancer patients referred by primary care physicians to the Department of Radiotherapy and Oncology in Chandigarh during one month. The following dates were recorded for each patient: first cancer related symptom noticed by patient, first consultation with primary care physician, first oncology consultation, date therapy began (and intent of therapy — curative or palliative).
Three delay intervals were calculated: patient approaching primary care physician (patient delay), primary care physician diagnosing/referring to oncologist (physician delay), and oncologist starting treatment (oncologist delay). Multivariate analysis revealed the demographic and socioeconomic factors contributing to the delay, and the impact of this delay on treatment.
There was an average total delay of about six months between the first symptom and the initiation of treatment. Patients and primary care physicians contributed statistically significant delays — an average of four months and three weeks, respectively. Oncologists delayed for an average of ten days but this did not significantly contribute to the overall delay.
Dr Miriyala said: “Patients were found to be the source of most delays in diagnosis — some waited less than a week before seeing a doctor but others waited three years. Less educated patients were significantly less likely to get an early consultation with their doctor than those with higher education. Campaigns are needed to increase patient awareness about symptoms and screening.”
Some primary care physicians delayed up to five years before referring patients to an oncologist, instead treating patients for “presumed non-malignant conditions.” Dr Miriyala said: “About 25% of patients waited more than one month for their physician to refer them. Doctors in rural areas had significantly longer delays, suggesting that referral systems need improvement. Mandatory continuing medical education (CME) could increase doctors’ awareness about early diagnosis and referral, as could more oncology teaching hours and rotations in the undergraduate curriculum.”
About 6% of patients experienced delays of more than one month before their oncologist started treatment. Oncologist delay was significantly correlated to the disease site, with longer delays for head and neck cancer and shorter delays for brain tumours.
Dr Miriyala said: “This can be attributed to the diagnosis and staging requirements for different malignancies. Most head and neck cancers require endoscopic assessments and biopsies before initiation of treatment, resulting in longer delays, while diagnosis is made after therapeutic surgery for most brain tumours, resulting in shorter delays. Cancers (like brain tumours) that present as medical or surgical emergencies are more likely to be addressed earlier. Improving the quality and quantity of infrastructure at tertiary centres would help reduce the oncologists’ delay.”
Patients with longer delays were significantly more likely to receive palliative treatment than those with shorter delays. Dr Miriyala said: “Outcomes were not evaluated in our study but it is common knowledge that treatment with palliative intent leads to inferior outcomes compared to that with curative intent. Our research suggests that reducing delays might improve outcomes for cancer patients.”
Commenting on the findings, Dr Sing-Huang Tan, senior consultant, Department of Haematology-Oncology, National University Cancer Institute, Singapore (NCIS), said: “Patients may delay seeking medical care because of failure to recognise symptoms, family or work commitments, or anxiety and fear. Patients in certain parts of Asia in particular may have ingrained cultural beliefs or preferences to self-medicate with traditional treatments, poor access to healthcare, or socioeconomic limitations which could hypothetically lead to long delays before seeing a doctor.”
“Primary healthcare providers are sometimes faced with diagnostic dilemmas when a patient presents with ambiguous symptoms,” continued Dr Tan. “A large majority of cancers present symptomatically, but symptoms may be subtle especially in the early stages in certain cancer types such as gastric, pancreatic or ovarian cancers, as opposed to say a more obvious palpable mass such as in breast cancer.”
Dr Tan concluded: “This study highlights the perils of diagnostic delays and how they can lead to changes in treatment intent and presumably ultimately affect cancer outcomes. It is important to educate the general public to recognise suspicious symptoms which demand medical help, and to go for screening tests such as those that identify breast, colon and cervical cancers before symptoms develop.”