Gastric cancer--delay in diagnosis and its causes

Factors influencing symptom appraisal and help-seeking of older adults with possible cancer: a mixed-methods systematic review

BACKGROUND

The cancer burden falls predominantly on older (≥65 years) adults. Prompt presentation to primary care with cancer symptoms could result in earlier diagnosis. However, patient symptom appraisal and help-seeking decisions involving cancer symptoms are complex and may be further complicated in older adults.

AIM

To explore the effect of older age on patients' appraisal of possible cancer symptoms and their decision to seek help for these symptoms.

DESIGN AND SETTING

Mixed-methods systematic review.

METHOD

MEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane Library, Web of Science Core Collection, ASSIA, the ISRCTN registry, and the National Institute for Health and Care Excellence were searched for studies on symptom appraisal and help-seeking decisions for cancer symptoms by adults aged ≥65 years. Studies were analysed using thematic synthesis and according to the Synthesis Without Meta-Analysis guidelines.

RESULTS

Eighty studies were included with a total of 32 995 participants. Studies suggested a possible association between increasing age and prolonged symptom appraisal interval. Reduced knowledge of cancer symptoms and differences in symptom interpretation may contribute to this prolonged interval. In contrast, in the current study a possible association was found between increasing age and prompt help-seeking. Themes affecting help-seeking in older adults included the influence of family and carers, competing priorities, fear, embarrassment, fatalism, comorbidities, a desire to avoid doctors, a perceived need to not waste doctors' time, and patient self-management of symptoms.

CONCLUSION

This review suggests that increasing age is associated with delayed cancer symptom appraisal. When symptoms are recognised as potentially serious, increasing age was associated with prompt help-seeking although other factors could prolong this. Policymakers, charities, and GPs should aim to ensure older adults are able to recognise potential symptoms of cancer and seek help promptly.

Gaps in Providers' Knowledge Delays Gastric Cancer Diagnosis

BACKGROUND

Previous studies have suggested that symptomatic cancer patients often experience delays in diagnosis (DD). However, DD of gastric cancer within the USA and etiology of those delays are not understood. Our study quantifies the proportion of gastric cancer patients experiencing DD and contributing barriers of care.

METHODS

We conducted a single institution retrospective review of 256 gastric cancer patients treated between 2015 and 2020. Patients with an interval from symptom onset to diagnosis of > 90 days were classified as having DD and categorized into one of the following barriers of care: access, provider knowledge/skills, and patient factors. Chi-square tests were used to analyze categorical group differences. Non-pooled t-tests and ANOVA were used to compare differences in group means.

RESULTS

A total of 59 patients (23%) had DD. Among patients with DD, the mean time from symptom onset to diagnosis was 229 days vs 30 days in the non-delayed group (p < 0.0001). The most common barrier of care was provider knowledge/skills gaps (44%), followed by access (36%) and patient-related factors (20%). Only 5% of patients who experienced delays reported abdominal pain alone, with the remaining 95% of patients reporting more than one symptom including obstruction, gastrointestinal bleeding, or weight loss.

CONCLUSION

Patients often face lengthy delays in gastric cancer diagnosis which arise from healthcare system factors such as access barriers or gaps in provider knowledge/skills. Understanding concerning alarm symptoms and addressing identified barriers will expedite patient diagnosis and are prime opportunities to improve outcomes for gastric cancer patients.

Factors affecting the decision to investigate older adults with potential cancer symptoms: a systematic review

BACKGROUND

Older age and frailty increase the risk of morbidity and mortality from cancer surgery and intolerance of chemotherapy and radiotherapy. The effect of old age on diagnostic intervals is unknown; however, older adults need a balanced approach to the diagnosis and management of cancer symptoms, considering the benefits of early diagnosis, patient preferences, and the likely prognosis of a cancer.

AIM

To examine the association between older age and diagnostic processes for cancer, and the specific factors that affect diagnosis.

DESIGN AND SETTING

A systematic literature review.

METHOD

Electronic databases were searched for studies of patients aged >65 years presenting with cancer symptoms to primary care considering diagnostic decisions. Studies were analysed using thematic synthesis and according to the Synthesis Without Meta-analysis guidelines.

RESULTS

Data from 54 studies with 230 729 participants were included. The majority of studies suggested an association between increasing age and prolonged diagnostic interval or deferral of a decision to investigate cancer symptoms. Thematic synthesis highlighted three important factors that resulted in uncertainty in decisions involving older adults: presence of frailty, comorbidities, and cognitive impairment. Data suggested patients wished to be involved in decision making, but the presence of cognitive impairment and the need for additional time within a consultation were significant barriers.

CONCLUSION

This systematic review has highlighted uncertainty in the management of older adults with cancer symptoms. Patients and their family wished to be involved in these decisions. Given the uncertainty regarding optimum management of this group of patients, a shared decision-making approach is important.

Barriers and Facilitators Associated with Delays in the Diagnosis and Treatment of Gastric Cancer: a Systematic Review

BACKGROUND

The present study was conducted to identify barriers and facilitators of early diagnosis and treatment of gastric cancer.

METHODS

Comprehensive search was conducted on 2021 in various databases, including Medline, Web of science, and Scopus. Keywords such as gastric cancer, screening programs, endoscopy, barriers, facilitators, and factor were used for the search, as single or in combination. Also a manual search was done in valid scientific journals to find related full-text articles. The search results were entered into the Endonote-X8 software, which automatically removes duplicate articles. Then, the title and the abstract and finally, the  text of the articles were studied. Articles that addressed barriers and facilitators of early diagnosis and treatment of gastric cancer were included.

RESULTS

In according to the results of 22 included articles, delay time in the diagnosis and treatment of gastric cancer were high, and factors such as age, sex, race and ethnicity, economic and social status, access to diagnostic services, implementation of screening programs, type and accuracy of screening methods, use of insurance services, error in care services, and presence of gastrointestinal symptoms were considered to be contributing factors in this regard.

CONCLUSIONS

It seems that to reduce delay in the diagnosis and treatment of gastric cancer, factors such as implementing screening programs using acceptable methods with high sensitivity and accuracy with a high level of participation, increasing insurance coverage and reducing the share of people in payments, increasing people's access to diagnostic services, educating people about the symptoms and risks of gastric cancer, undertaking proper follow-up in patients and suspects cases identified in screening, as well as increasing patients' access to medical services through financial and insurance support are significantly important.

Socioeconomic and administrative factors associated with treatment delay of esophageal and gastric carcinoma: Prospective study from a tertiary care centre in a developing country

This study was aimed to analyze the spectrum of time intervals, from the onset of symptoms to the commencement of treatment in esophagogastric cancers. Factors influencing these time delays and correlation between these time points with variables including socioeconomic strata, educational level, histopathology, location of tumor and the initial modality of treatment were assessed.

STUDY SETTING AND METHODS

A prospective analysis of patients with esophagogastric cancer presenting to a single tertiary care unit over a period of 12 months was performed. Histopathology other than adenocarcinoma and squamous cell were excluded.

RESULTS

202 patients were enrolled in the study. Most patients presented with advanced disease, i.e. 91.5 % of esophageal and 90 % of gastric malignancies belonged to either stage 3 or stage 4 as per American Joint Committee on Cancer (AJCC) tumor-node-metastasis (TNM) staging system. The median delay from the appearance of the first symptoms to initiation of treatment was 15 weeks (range 4-64). Patient related factors contributed to a significant delay [median of 5 weeks (range 1-24)]. Administrative factors were responsible for median delay of 3 weeks (range 0.5-20). Curative multimodality treatment was administered in 62.5 % of patients. Significant longer delay was influenced by socioeconomic strata, educational level, evaluation by non-specialist (p < 0.05). No relationship was noted between histopathology, location of tumor or initial modality of treatment.

CONCLUSIONS

Delays in our setting is much more than that is seen in Western and even some Asian countries. An important component of delay is administrative related factors. These may be intervened at the hospital level compared to other factors which may need long term community oriented approaches.

Measures of psychosocial factors that may influence help-seeking behaviour in cancer: A systematic review of psychometric properties

Advanced stage cancer is frequently attributed to delays in presentation to a healthcare professional. To reduce undue delay, it is imperative to understand the reasons underlying help-seeking behaviour and to measure those using valid and reliable tools. This systematic review aimed to identify how studies have measured psychosocial factors affecting time to presentation for (potential) cancer symptoms. A total of 35 studies were included. Most studies failed to use valid and reliable tools, and predominantly provided inconclusive results regarding psychosocial factors and time to presentation when no or minimal psychometric evidence was present. Consequently, measure selection and future measure development should be guided by psychometric principles.

AMPK activator AICAR promotes 5-FU-induced apoptosis in gastric cancer cells

The aim of the present study was to determine the effect of AICAR, an AMPK activator, on apoptosis in gastric carcinoma cells (SGC-7901) with or without 5-fluorouracil (5-FU). SGC-7901 cells were treated with AICAR (0.2-5 mM, for 24-48 h) with or without 5-FU. Cell viability was determined using MTT assay, while apoptosis were measured through the evaluation of active caspase-3 activity and DNA fragmentation. Real-time PCR was employed to determine the expression of tumor suppressor and multi-drug resistant (mdr1) gene. Cleaved caspase-3 and phosphorylated AMPK (p-AMPK) were measured by Western blot. AICAR significant reduced cellular viability but increased apoptosis in a time- and dose-dependent manner, which is associated with an increase in p-AMPK levels. Importantly, AICAR enhanced the sensitivity to 5-FU-induced reduction of cellular viability and increased apoptosis in SGC-7901 cells. Furthermore, AICAR increased tumor suppressor genes [F-box and WD repeat domain containing 7 (FBXW7), semaphorin III/F (SEMA3F), and p21(Cip1) (p21)] but reduced mdr1 expression. Finally, p-AMPK levels were reduced in 5-FU-resistant gastric cancer cells compared to human immortalized gastric epithelial cell line and 5-FU-sensitive gastric cancer cells. AICAR not only induces apoptosis alone but also enhances pro-apoptotic effect of 5-FU in SGC-7901 cells, which lays an experimental foundation to develop AICAR as a chemotherapeutic sensitizer against gastric cancer.

Diagnostic difficulty and error in primary care--a systematic review

BACKGROUND

Diagnostic error in primary care can have serious implications for the patient, the clinician and the health-care system, possibly more so than other types of error.

OBJECTIVE

To identify common characteristics of diseases that GPs may misdiagnose.

METHODS

Systematic search of the MEDLINE and EMBASE databases for primary research on diagnostic error/delay in primary care. Papers on system errors, patient delay, case reports, reviews, opinion pieces, studies not based on actual cases and studies not using a systematic sample were excluded from the review. Twenty-one papers were included. All papers were assessed for quality using the GRADE system. Common features were identified across diseases and presentations that made diagnosis difficult and led to error/delay.

RESULTS

Most studies were retrospective cohorts of patients recruited in hospital and collected data from patient interviews and/or hospital records, resulting in incomplete and potentially biased information. It was usually not possible to determine preventability of the delay. Some conditions were extremely rare, suggesting a specialist research interest rather than an increased rate of misdiagnosis. Conditions investigated were malignancies, myocardial infarction, meningitis, dementia, iron deficiency anaemia, asthma, tremor in the elderly and HIV. Common features of difficulty were atypical presentations, non-specific presentations, very low prevalence, the presence of co-morbidity and perceptual features and could be missed.

CONCLUSIONS

Misdiagnosis in primary care covers a wide range of conditions that may be related in the manner in which they present. The challenge is to identify ways of supporting the diagnostic process in potentially difficult presentations.

Systematic review of factors influencing patient and practitioner delay in diagnosis of upper gastrointestinal cancer

As knowledge on the causation of cancers advances and new treatments are developed, early recognition and accurate diagnosis becomes increasingly important. This review focused on identifying factors influencing patient and primary care practitioner delay for upper gastrointestinal cancer. A systematic methodology was applied, including extensive searches of the literature published from 1970 to 2003, systematic data extraction, quality assessment and narrative data synthesis. Included studies were those evaluating factors associated with the time interval between a patient first noticing a cancer symptom and presenting to primary care, between a patient first presenting to primary care and being referred to secondary care, or describing an intervention designed to reduce those intervals. Twenty-five studies were included in the review. Studies reporting delay intervals demonstrated that the patient phase of delay was greater than the practitioner phase, whilst patient-related research suggests that recognition of symptom seriousness is more important than recognition of the presence of the symptom. The main factors related to practitioner delay were misdiagnosis, application and interpretation of tests, and the confounding effect of existing disease. Greater understanding of patient factors is required, along with evaluation of interventions to ensure appropriate diagnosis, examination and investigation.

[Analysis of the delay in surgical treatment of adenocarcinoma of the prostate]

INTRODUCTION

The prostate cancer is an important cause of men's mortality in our society.

PURPOSE

To know the time of delay in to realise the surgical treatment of the prostate cancer.

MATERIALS AND METHODS

Analysis of 30 cases of patients treated with radical prostatectomy, cuantifying the time of delay in all the periods of the process.

RESULTS

Appointment in general practitioner-first appointment in urology: 21.7 days. First appointment in urology-biopsy: 22.8. Biopsy-diagnosis: 34.3. Diagnosis-appointment of anesthesiology: 28.5. Anesthesiology-radical prostatectomy: 25.7.

CONCLUSIONS

There are actions for to reduce the delay in to perform the diagnosis or treatment, where we can act how an improvement plan: to give poblational education in general and information to the patient in particular, to analyze the rules of medical action, to improve the coordination between level, to improve the flexibility in outpatients appointment and time waiting for diagnosis test and treatment, to correct the temporality, to create clinical units of many specialties and to improve the politics of health.

[Duration of the diagnostic process for lung cancer versus other solid tumors at the National Oncology Institute of Ecuador]

OBJECTIVE

To determine the duration of the outpatient diagnostic process for lung cancer in comparison to that of other solid organ tumors/all tumors at the National Oncology Institute-Society to Fight Cancer (ION-SOLCA) of Ecuador.

PATIENTS AND METHODS

All patients with non-small cell lung cancer (NSCLC) seen between January 1 and December 31, 1995 at the ION-SOLCA, a specialized tertiary care hospital in Guayaquil, Ecuador, were studied. The duration of the patients' diagnostic process was compared to that of other patients with solid organ tumors (1 control per NSCLC patient).

DESIGN

Retrospective study of health care services to measure the duration of each stage of the diagnostic process for cancer patients at the ION-SOLCA.

MEASURES

The main variable was the duration of the diagnostic process. The duration of each phase of the process was also recorded.

RESULTS

Results are given as means ( standard deviations, with standard errors between parentheses). The overall duration of the diagnostic process for all solid organ tumors (lung and others) at the ION-SOLCA was 54.5 days 62.3 (7.6). No differences were detected between the duration of diagnosis for lung and other tumors. The durations of the different phases of diagnosis were as follows: from the first pre-admission contact with the hospital until a visit with a specialist, 12.5 days 11.4 (1.4); from the visit with a specialist until a diagnostic procedure, 33.3 days 57 (7); and from the diagnostic procedure until the pathological diagnosis, 8.7 days 6.9 (0.8).

CONCLUSIONS

Outpatient evaluation is an inefficient, slow and potentially dangerous process in cases in which the probability of a cancer diagnosis is high. A more interventionist process involving hospital admission may accelerate diagnosis in such cases.

H2-receptor antagonists may increase the risk of cardio-oesophageal adenocarcinoma: a case-control study

Adenocarcinoma of the lower oesophagus and the gastric cardia has shown a dramatic worldwide increase in incidence over the last 25 years, but the cause is unknown. A large number of drugs have been introduced over this period of time, and it has been suggested that drugs that relax the lower oesophageal sphincter (DRLOS) might be causative, and on the other hand that non-steroidal anti-inflammatory drugs (NSAIDS) may be protective. H2-receptor antagonists (H2RAs) may allow achlorhydric reflux to continue without symptoms, and it is postulated that such asymptomatic reflux is uncontrolled by the usual conservative measures and may lead to increased oesophageal damage. H2RAs were first marketed in 1970 and might be the cause of the observed increase of cardio-oesophageal adenocarcinoma (COA). In a case-control study, the records of 56 subjects who died of COA in the period 1 January 1990 to 31 December 1992 were compared with those of 56 age-/sex-matched controls who died of myocardial infarction. They were 28 females and 84 males, mean age 69.8 years. The NHS records containing the lifetime prescription history of each subject were retrieved from the health authority. Each prescription was recorded, omitting drugs taken in the two years before diagnosis. Analysis was performed using conditional logistic regression. Other variables, including the use of antacids, steroids, smoking and alcohol, were also examined. Subjects dying of COA were more likely to have consumed H2RAs (relative risk (RR) 7.50, 95% CI 1.33-42.09, P < 0.02). On the other hand, they were less likely to have consumed NSAIDs (RR 0.16, 95% CI 0.03-0.93, P < 0.04) or DRLOS (RR 0.14, 95% CI 0.02-1.0, P = 0.05). This study supports a protective effect from NSAIDs against COA, but the similar effect of DRLOS is related to the increased use of cardiac drugs in the control group. H2RAs appear to have a harmful effect, which may be related to the worldwide increase in COA. However, the trend may have been apparent before cimetidine was widely available, and it is possible that the cause is multi-factorial.

Emergency admission for cancer: a matter of survival?

The objective of this study was to compare the pre-hospital health care process, clinical characteristics at admission and survival of patients with a digestive tract cancer first admitted to hospital either electively or via the emergency department. The study involved cross-sectional analysis of information elicited through personal interview and prospective follow-up. The setting was a 450-bed public teaching hospital primarily serving a low-income area of Barcelona, Catalonia, Spain. Two hundred and forty-eight symptomatic patients were studied, who had cancer of the oesophagus (n = 31), stomach (n = 70), colon (n = 82) and rectum (n = 65). The main outcome measures were stage, type and intention of treatment and time elapsed from admission to surgery; the relative risk of death was calculated using Cox's regression. There were 161 (65%) patients admitted via the emergency department and 87 (35%) electively. The type of physician seen at the first pre-hospital visit had more often been a general practitioner in the emergency than in the elective group (89% vs 75%, P < 0.01). Emergency patients had seen a lower number of physicians from symptom onset until admission, but two-thirds had made repeated visits to a primary care physician. Emergency patients were less likely to have a localized tumour and a diagnosis of cancer at admission, and surgery as the initial treatment. Median survival was 30 months for elective patients and 8 months for emergency patients (P < 0.001), and the relative risk of death (RR) was 1.83 (95% confidence interval, CI, 1.32-2.54). After adjustment for strong prognostic factors, emergency patients continued to experience a significant excess risk (RR = 1.58; CI 1.10-2.27). In conclusion, in digestive tract cancers, admission to hospital via the emergency department is a clinically important marker of a poorer prognosis. Emergency departments can only partly counterbalance deficiencies in the effectiveness of and integration among the different levels of the health system.

Do we believe what patients say about their neoplastic symptoms? An analysis of factors that influence the interviewer's judgement

In order to analyze factors that influence an interviewer's judgement of the validity of responses given by patients on the duration of their neoplastic signs and symptoms, 183 consecutive symptomatic patients hospitalized for a digestive tract neoplasm were personally interviewed. The validity of the answers was judged by the interviewers to be high in 156 cases (85%), and low in 27 (15%). The subjective validity of the interview (SVI) was inversely related to the time elapsed from first medical symptom to interview (TFMSI), even after adjusting for the duration of the interview (p < 0.05). SVI was not influenced by whether patient and interviewer agreed on the first symptom. SVI was inversely related to educational level (p < 0.01) and to occupational class (p = 0.04). Patients whose Karnofsky's Index (KI) was > or = 80 were over twice as likely to yield valid responses (TFMSI-adjusted odds ratio [OR] = 2.82, p = 0.037). Multivariate analyses selected education, TFMSI and KI as independent predictors of the interviewer assessment. The SVI of patients admitted to the hospital through the Emergency Department was lower than that of subjects whose admission was planned (OR = 6.49, p = 0.005). In this study SVI related in a logical manner to the characteristics of the interview, of the subjects and of their clinical course. It hence appeared to reasonably estimate the validity of data collected. Identifying factors that affect the reliability of patients' responses would help increase the validity of studies on the duration of cancer symptoms.

Time lag to diagnosis of bladder cancer--influence of psychosocial parameters and level of health-care provision

Delay in diagnosis of carcinoma of the urinary bladder was studied in 343 patients. The median patient's delay (time from first symptom to first consultation) was 15 days, and was longer when the only presenting symptom was urgency of micturition than when it was haematuria (45 vs. 5 days, p < 0.001). In advanced (T2-T4) tumour, patient's delay was 21 days and in Ta-T1 it was 13 days (NS). The median doctor's delay (time from first consultation to diagnosis) was 62 days. It comprised two phases: A from consultation to first referral and B from first referral to diagnosis-respective medians 6 and 47 days. Median doctor's delay (A+B) was longer when the initial consultation was with a general practitioner than with a urologist (78 vs. 21 days, p < 0.001) and longer in patients older than 70 years (69 vs. 54 days, p < 0.01). Doctor's delay correlated with symptoms, being longest in cases with only urgency and shortest in haematuria plus pain (114 vs. 44 days, p < 0.001), and also with number of referrals (33, 63, 230 and 117 days, respectively, for 0, 1, 2 and 3 referrals). More women than men were referred a second or third time (25.6% vs. 8.6%, p < 0.001), and doctor's delay was longer for women (76 vs. 59 days, p < 0.05). A questionnaire completed by 203 of the 229 surviving patients revealed no significant correlation between psychosocioeconomic factors and patient's delay.

Delay versus help seeking for breast cancer symptoms: a critical review of the literature on patient and provider delay

Patient delay in seeking help for breast cancer symptoms and provider delay in treating those symptoms combine to decrease a woman's potential for breast cancer survival. This paper reviews the literature on patient and provider delay published since 1975. Meta-analysis of 12 studies using common definitions of patient delay estimates that 34% of women with breast cancer symptoms delay help seeking for 3 or more months. Provider delay appears to be both under researched and underestimated. This review identifies the factors that have been advanced as contributing to patient and provider delay, evaluating the support for each of these reported findings. Theory-based hypotheses emerging from the reviewed studies highlight foci for future investigations.

Diagnostic delay, clinical stage, and social class: a hospital based study

STUDY OBJECTIVE

To measure delay in admission to a large hospital and to study the role of social class and other potential determinants of delay.

DESIGN

Interview of a 10% sample of newly diagnosed patients admitted to medical or surgical wards, and all those admitted for external hernia or colon cancer between June 1989 and May 1990.

SETTING

The largest hospital in an Italian region of five million inhabitants.

SUBJECTS

The study population consisted of 330 patients with a range of different medical and surgical conditions, 83 patients with external hernias, and 97 patients with colon cancers.

MEASUREMENTS AND MAIN RESULTS

After patient interview and discharge from hospital, the clinical record was consulted for information on the length of stay and the diagnosis, and in particular for the staging of hernia or colon cancer (according to the protocol of the Jefferson Medical College). Multiple logistic regression was used to estimate odds ratios and 95% confidence intervals. There was an association between advanced disease at hospital admission and the patient's educational level. In each of the three groups of patients, those with the highest educational level had a 30% or lower probability of being admitted to hospital with advanced disease compared with those with the lowest education level (after allowance for sex, age, area of residence, and marital status).

CONCLUSION

Lower social class was associated with a more advanced clinical stage of hernia or colon cancer, and with a higher probability of urgent admission to the hospital for a newly diagnosed disease. Delay in seeking care, did not however, seem to explain the social class differentials for disease stage.

Gastric cancer detected by mass survey. Comparison between mass survey and outpatient detection

Although the incidence of stomach cancer in Japan has decreased only slightly, the mortality has decreased markedly. The main reason for this success is the early diagnosis of cancer, to which mass survey has contributed. From 1964 to 1985, 290,914 screening examinations were done at the Mass Survey Center of the Cancer Institute Hospital, Tokyo. In 474 people (0.16%) cancer was detected, and of those, 52% were in an early stage of disease. For the mass survey group, the 5-year survival rate was 80%, and the 10-year survival rate 78.5%. The outpatient group rates were 56.2% and 55.1% for 5 and 10 years, respectively. This difference could be explained by the higher percentage of early gastric cancer and less extensive lymph node metastasis in patients with serosal involvement, in the outpatient group. The 10-year survival results show that early treatment results in an absolute better long-term survival. This refutes the hypothesis that 5-year survival rates of early gastric cancer patients are biased because of lead time of early diagnosis. Mass survey, even for a small district, provides an excellent opportunity to detect gastric cancer in people without symptoms. The high percentage of cases detected with cancer in an early stage reduces stomach cancer mortality.