Psychological factors and patient delay in patients with head and neck cancer

Factors affecting stroke pre-hospital delay behavioral intention among community residents: A path analysis

BACKGROUND

Pre-hospital delay is the major cause of stroke treatment delay, and behavioral intention is considered to be the most direct predictor of behavior. Therefore, to effectively reduce stroke pre-hospital delay, it is essential to further understand the relationship between stroke pre-hospital delay intention (SPDBI) and its social-psychological influencing factors, namely personality traits, social support and coping style.

AIM

This study aims at examining the relationships among personality traits, coping style, social support, and SPDBI.

METHODS

A cross-sectional, self-administered questionnaire was distributed to 845 residents. The content of the questionnaire included demographic information, the knowledge of "Stroke 120", Ten-Item Personality Inventory-Chinese version, Simplified Coping Style Questionnaire, Perceived Social Support Scale and SPDBI Scale. Path analysis was used to investigate the relationship among SPDBI and its psychosocial influencing factors.

RESULTS

The final path model showed a good fit to the data (χ2/df = 2.981, RMSEA = 0.048, GFI = 0.936, CFI = 0.941). Extroversion (β = 0.106), positive coping (β = -0.110), negative coping (β = 0.150) and the knowledge of "Stroke 120" (β = -0.152) had only direct effects on SPDBI. While agreeableness (β = 0.113), openness (β = -0.121) and social support (β = -0.118) had direct effects on SPDBI, they also had indirect effects (β = -0.009; -0.022; -0.049) on SPDBI though positive coping.

CONCLUSIONS

Adequate social support and positive coping of health threat may reduce residents' SPDBI. Meanwhile, the interventions to reduce SPDBI should take personality differences into consideration.

Psychosocial factors and patient and healthcare delays in large (class T3-T4) oral, oropharyngeal, and laryngeal carcinomas

BACKGROUND

Psychosocial factors and socioeconomic status have been associated with incidence, survival, and quality of life among patients with head and neck cancer. We investigated the association between different psychosocial factors, socioeconomic status, and patient delays in T3-T4 oral, oropharyngeal, and laryngeal cancer.

PATIENTS AND METHODS

We conducted a nationwide prospective questionnaire-based study (n = 203) over a 3-year period.

RESULTS

We found no association between psychosocial factors (depression, social isolation, loneliness, and cynical hostility) and patient delay. Depression was three times more common among head and neck cancer patients compared with the general Finnish population. Head and neck cancer patients had lower educational levels and employment status, and were more often current smokers and heavy drinkers.

CONCLUSIONS

Although we found no association between patient delay and psychosocial factors, patients diagnosed with a large head and neck cancer appeared to have a lower socioeconomic status and higher risk for developing depression, which should be considered in clinical practice.

Associations Between Psychiatric Diagnoses on Length of Stay and Mortality After Rib Fracture: A Retrospective Analysis

INTRODUCTION

Concurrent psychiatric diagnoses adversely impact outcomes in surgical patients, but their relationship to patients with rib fracture after trauma is less understood. We hypothesized that psychiatric comorbidity would be associated with increases in hospital length of stay (LOS) and mortality risk after rib fracture.

MATERIALS AND METHODS

The 2017 National Inpatient Sample was queried for adult patients who were admitted with rib fracture after trauma. Mental health disorders were categorized into 34 psychiatric diagnosis groups (PDGs) using clinical classifications software refined for International Classification of Diseases-10. Outcomes of interest were LOS and mortality. Bivariable analysis determined associations between PDGs, patient demographics, hospital characteristics, and outcomes. Logistic regression was performed to identify adjusted effects on mortality, and linear regression was performed to identify effects on LOS.

RESULTS

Of 32,801 patients, median age was 61 y (IQR 46-76), and median LOS was 5 d (IQR 3-9). No PDGs were associated with increased odds of mortality. Concurrent diagnosis of schizophrenia spectrum (Coeff. 3.5, 95% CI 2.7-4.4, P < 0.001) or trauma- or stressor-related (Coeff. 1.6, 95% CI 0.9-2.5, P < 0.001) disorders demonstrated the greatest association with prolonged LOS. Increased odds of death and prolonged hospital stay were also associated with male sex, non-White patient race, and surgery occurring at urban and public hospitals.

CONCLUSIONS

Psychiatric comorbidities are associated with death after rib fracture but are associated with increased LOS. These findings may help promote multidisciplinary patient management in trauma.

Stage shift and relative survival for head and neck cancer during the 2020 COVID-19 pandemic: a population-based study of temporal trends

Objective

During the first wave of the COVID-19 pandemic in 2020, non-essential health services were suspended in Belgium, and the public was ordered to socially isolate. Underdiagnosis of cancer during this period was reported worldwide. Certain risk factors for head and neck cancer (HNC) overlap with those for COVID-19 incidence and mortality, making underdiagnosis and subsequent stage shift of this potentially rapidly progressing cancer a major concern. We aimed to analyze incidence, clinical stage at presentation, and survival of patients diagnosed with HNC in 2020 in Belgium, considering recent temporal trends.

Methods

Using population-based data from the Belgian Cancer Registry (BCR), we extrapolated 2017-2019 trends in incidence, clinical stage, and 1-year relative survival (1yRS) of HNC to create an expected value for 2020 and compared this to the observed value.

Results

There were 9.5% fewer HNCs diagnosed in 2020, compared to the predicted incidence. Underdiagnosis was larger for males (-11.8%), patients aged 50-64 (-11.2%) and 65-79 (-11.1%), and for oral cavity cancer (-17.6%). Shifts to more advanced stages were observed in larynx and oropharynx tumors and for (male) patients aged 80+. A 2.4 percentage point decline in 1yRS was observed, relative to the increasing trends in 1yRS (2017-2019).

Conclusion

The COVID-19 pandemic led to underdiagnosis of HNC, resulting in shifts to more advanced stage at presentation in certain subgroups. A stage shift can be expected for the 9.5% of tumors not yet diagnosed at the end of 2020. HNC patients diagnosed in 2020 suffered higher than expected mortality.

Time required for prophylactic oral care in head and neck cancer patients scheduled for radiotherapy: A single center, prospective cohort study

BACKGROUND

Prophylactic oral care (POC) before radiotherapy (RT) is an adjunct but an integral process toward preparing patients for RT, however, time to be invested in POC remains unexplored.

METHODS

Prospective treatment records were maintained in head and neck cancer patients, who received POC following a standardized protocol with definite timelines. Data collected for oral treatment time (OTT), interruption in RT due to oro-dental issues, future extraction(s), and incidence of osteoradionecrosis (ORN) up to 18 months after treatment were analyzed.

RESULTS

Three hundred thirty-three patients, 275 males and 58 females, mean age 52.45 ± 11.2 years were included. Mean OTT was 21.0 ± 6.2 days and was influenced significantly with the number of extractions (p < 0.00). There was no interruption in RT schedule due to oro-dental issues. Five patients were diagnosed with ORN.

CONCLUSION

Performing POC as demonstrated aid in timely removal of nidus of infection(s), perform RT as scheduled, and maintain satisfactory oral health through the survivorship of patients.

Patient and health care delays in large (class T3-T4) oral, oropharyngeal, and laryngeal carcinomas

BACKGROUND

Head and neck cancers (HNCs) are often diagnosed at an advanced stage. We investigated the lengths and factors associated with patient, primary health care (PHC), and specialist care (SC) delays in T3-T4 oral, oropharyngeal, and laryngeal cancer.

METHODS

A nationwide prospective questionnaire-based study (n = 203) with the 3-year long data collection period.

RESULTS

The median patient, PHC and SC delays were 58, 13, and 43 days, respectively. Lower level of education, heavy alcohol use, hoarseness, difficulties breathing, and eventual palliative treatment associated with a longer patient delay. A lump on the neck or facial swelling associated with a shorter PHC delay. Conversely, if symptoms were treated as an infection, PHC delay was longer. The treatment modality and tumor site affected SC delay.

CONCLUSIONS

Patient delay stands as the most notable factor contributing to delays before treatment. HNC symptom awareness thus remains especially important among HNC risk groups.

Implementing a Tailored Psychosocial Distress Screening Protocol in a Head and Neck Cancer Program

OBJECTIVES/HYPOTHESIS

Psychosocial distress is common among patients with head and neck cancer (HNC) and is associated with poorer quality of life and clinical outcomes. Despite these risks, distress screening is not widely implemented in HNC care. In this study, we investigated the prevalence of psychosocial distress and its related factors in routine care of patients with HNC.

METHODS

Data from medical records between September 2017 and March 2020 were analyzed. Psychosocial distress was measured by the National Comprehensive Cancer Network's Distress Thermometer (DT), and a modified HNC-specific problem list; depression and anxiety were assessed using the Patient Health Questionnaire-4. Descriptive statistics and logistic regression were conducted to report prevalence of distress, depression and anxiety, and factors associated with clinical distress. Implementation outcomes, including rates of referrals and follow-up for distressed patients, are also reported.

RESULTS

Two hundred and eighty seven HNC patients completed the questionnaire (age 64.3 ± 14.9 years), with a mean distress score of 4.51 ± 3.35. Of those, 57% (n = 163) reported clinical distress (DT ≥ 4). Pain (odds ratio [OR] = 3.31, 95% CI = 1.75-6.26), fatigue (OR = 2.43, 95% CI = 1.1.7-5.05), anxiety (OR = 1.63, 95% CI = 1.30-2.05), and depression (OR = 1.51, 95% CI = 1.04-2.18) were significantly associated with clinical distress (P < .05). Of patients identified as distressed, 79% received same-day psychosocial evaluation.

CONCLUSIONS

Clinical distress was identified in 57% of patients who completed the questionnaire, suggesting that an ultra-brief psychosocial screening protocol can be implemented in routine ambulatory oncology care, and identifies patients whose distress might otherwise go unrecognized.

LEVEL OF EVIDENCE

4 Laryngoscope, 132:1600-1608, 2022.

Evaluating the reasons for delays in treatment of oral cavity cancer patients

The growing increase in oral cavity cancer (OSCC) incidence constitutes a severe diagnostic-therapeutic problem – and early diagnosis, as well as medical treatment remain important priorities of maxillofacial oncology. The aim of this paper was to determine the reasons for delays in the diagnostics and treatment of oral cavity cancer patients. The study focused on 248 patients (=56.1 years) post-surgery, in which delays in diagnostics and treatment were reported. As for the causes, most frequently, in 171 cases (69.0%), patient delays were reported, in 56 cases, physician delays were observed, and in 21 cases (8.5%), organizational reasons were to blame. The median time period between the onset of the symptoms and seeking medical attention was 143 days. Time interval between the first contact with a doctor and commencement of oncological treatment was 33.2 days approximately. The majority of the patients were not aware of the oral cavity cancer risk. Misdiagnosis of symptoms as inflammation, as well as prolonged antibiotic therapy and diagnostics constitute main reasons for physician and organization-al/health care system delays. Raising patients’ awareness of cancer risk, as well as educational and promotional programs for physicians are the principal goals of a strategy aiming to enhance oral cancer diagnosis.

Clinicians' Views of Patient-initiated Follow-up in Head and Neck Cancer: a Qualitative Study to Inform the PETNECK2 Trial

AIMS

Current follow-up for head and neck cancer (HNC) is ineffective, expensive and fails to address patients' needs. The PETNECK2 trial will compare a new model of patient-initiated follow-up (PIFU) with routine scheduled follow-up. This article reports UK clinicians' views about HNC follow-up and PIFU, to inform the trial design.

MATERIALS AND METHODS

Online focus groups with surgeons (ear, nose and throat/maxillofacial), oncologists, clinical nurse specialists and allied health professionals. Clinicians were recruited from professional bodies, mailing lists and personal contacts. Focus groups explored views on current follow-up and acceptability of the proposed PIFU intervention and randomised controlled trial design (presented by the study co-chief investigator), preferences, margins of equipoise, potential organisational barriers and thoughts about the content and format of PIFU. Data were interpreted using inductive thematic analysis.

RESULTS

Eight focus groups with 34 clinicians were conducted. Clinicians highlighted already known limitations with HNC follow-up - lack of flexibility to address the wide-ranging needs of HNC patients, expense and lack of evidence - and agreed that follow-up needs to change. They were enthusiastic about the PETNECK2 trial to develop and evaluate PIFU but had concerns that PIFU may not suit disengaged patients and may aggravate patient anxiety/fear of recurrence and delay detection of recurrence. Anticipated issues with implementation included ensuring a reliable route back to clinic and workload burden on nurses and allied health professionals.

CONCLUSIONS

Clinicians supported the evaluation of PIFU but voiced concerns about barriers to help-seeking. An emphasis on patient engagement, psychosocial issues, symptom reporting and reliable, quick routes back to clinic will be important. Certain patient groups may be less suited to PIFU, which will be evaluated in the trial. Early, meaningful, ongoing engagement with clinical teams and managers around the trial rationale and recruitment process will be important to discourage selective recruitment and address risk-averse behaviour and potential workload burden.

Factors associated with diagnosis delay in head and neck cancer

INTRODUCTION AND OBJECTIVES

Tumour stage is an important prognostic factor in head and neck tumours. Many tumours are diagnosed in advanced stages despite almost universal healthcare and their being symptomatic. This paper seeks to determine the diagnostic delay in head and neck tumours in our health department, to analyse factors associated with delay and if it is associated with diagnosis in advanced stages.

METHODS

Retrospective study of 137 patients with head and neck cancer diagnosed from 2016-2018. Patient delay, delay in primary health care, delay in secondary health care, diagnostic delay and possible associated factors (smoking, location, stage, …) were evaluated.

RESULTS

Many patients (44.5%) were diagnosed in advanced stages. The median patient delay was 30 days. The median referral to otorhinolaryngology was 3.5 days. If the referral was made by another specialist (p = .008), the patients were under previous treatment (P=.000) and the tumours were in initial stages (P=.038) this delay was greater. The median from the first visit to otorhinolaryngology was 15 days, higher in regular referrals (43%) (P=.000). The median diagnostic delay was 12 days, higher in surgical biopsies (P=.000). The median professional delay was 58.5 days and total delay was 118.5 days.

CONCLUSIONS

Many head and neck tumours are diagnosed in advanced stages. A relationship was not found between diagnosis in advanced stages and diagnostic delay. However, steps must be taken to reduce these excessive delays.

Predictors of CRC Stage at Diagnosis among Male and Female Adults Participating in a Prospective Cohort Study: Findings from Alberta's Tomorrow Project

Colorectal cancer (CRC) is a leading cause of morbidity and mortality in Canada. CRC screening and other factors associated with early-stage disease can improve CRC treatment efficacy and survival. This study examined factors associated with CRC stage at diagnosis among male and female adults using data from a large prospective cohort study in Alberta, Canada. Baseline data were obtained from healthy adults aged 35–69 years participating in Alberta’s Tomorrow Project. Factors associated with CRC stage at diagnosis were evaluated using Partial Proportional Odds models. Analyses were stratified to examine sex-specific associations. A total of 267 participants (128 males and 139 females) developed CRC over the study period. Among participants, 43.0% of males and 43.2% of females were diagnosed with late-stage CRC. Social support, having children, and caffeine intake were predictors of CRC stage at diagnosis among males, while family history of CRC, pregnancy, hysterectomy, menopausal hormone therapy, lifetime number of Pap tests, and household physical activity were predictive of CRC stage at diagnosis among females. These findings highlight the importance of sex differences in susceptibility to advanced CRC diagnosis and can help inform targets for cancer prevention programs to effectively reduce advanced CRC and thus improve survival.

Disease Profile and Oncologic Outcomes After Delayed Diagnosis of Human Papillomavirus-Associated Oropharyngeal Cancer

OBJECTIVE

Diagnostic delay in human papillomavirus-associated oropharynx squamous cell carcinoma (HPV(+)OPSCC) is common due to nonspecific symptoms. We aim to describe the disease burden and oncologic outcomes of patients with HPV(+)OPSCC diagnosed >12 months after symptom onset.

STUDY DESIGN

This is a retrospective cohort study of HPV(+)OPSCC patients receiving intent-to-cure treatment (including surgery ± adjuvant therapy or primary chemoradiation).

SETTING

2006-2016, tertiary care center.

METHODS

Tumor stage was compared between patients with and without delayed diagnosis using χ² tests. Kaplan-Meier survival analysis with univariate and multivariable Cox regressions were used to determine the effect of diagnostic delay on oncologic outcomes.

RESULTS

In total, 664 patients were included. Compared to patients diagnosed <12 months from symptom onset (n = 601), those diagnosed at >12 months (n = 63) were more likely to have T4 disease and higher overall American Joint Committee on Cancer (AJCC) clinical stage at presentation (P < .01 for both). At 5 years, rates of overall survival, cancer-specific survival, progression-free survival, and distant metastases-free survival in the delayed diagnosis cohort were 80%, 90%, 80%, and 89%, respectively. A >12-month delay in diagnosis did not significantly impact overall survival (adjusted hazard ratio [aHR], 1.16; 95% CI, 0.58-2.31), cancer-specific survival (aHR, 0.83; 95% CI, 0.29-2.39), progression-free survival (aHR, 1.15; 95% CI, 0.56-2.37), or distant metastases-free survival (aHR, 1.00; 95% CI, 0.42-2.40) after adjusting for age, sex, and clinical AJCC stage (P > .05 for all).

CONCLUSIONS

Delayed diagnosis of HPV(+)OPSCC is associated with greater burden of disease at presentation, but oncologic outcomes remain favorable across treatment modalities. When appropriate, intent-to-cure therapy should be pursued despite diagnostic delay.

LEVEL OF EVIDENCE

Level III.

Factors associated with diagnosis delay in head and neck cancer

INTRODUCTION AND OBJECTIVES

Tumour stage is an important prognostic factor in head and neck tumours. Many tumours are diagnosed in advanced stages despite almost universal healthcare and their being symptomatic. This paper seeks to determine the diagnostic delay in head and neck tumours in our health department, to analyse factors associated with delay and if it is associated with diagnosis in advanced stages.

METHODS

Retrospective study of 137 patients with head and neck cancer diagnosed from 2016-2018. Patient delay, delay in primary health care, delay in secondary health care, diagnostic delay and possible associated factors (smoking, location, stage, …) were evaluated.

RESULTS

Many patients (44.5%) were diagnosed in advanced stages. The median patient delay was 30 days. The median referral to otorhinolaryngology was 3.5 days. If the referral was made by another specialist (p=.008), the patients were under previous treatment (P=.000) and the tumours were in initial stages (P=.038) this delay was greater. The median from the first visit to otorhinolaryngology was 15 days, higher in regular referrals (43%) (P=.000). The median diagnostic delay was 12 days, higher in surgical biopsies (P=.000). The median professional delay was 58.5 days and total delay was 118.5 days.

CONCLUSIONS

Many head and neck tumours are diagnosed in advanced stages. A relationship was not found between diagnosis in advanced stages and diagnostic delay. However, steps must be taken to reduce these excessive delays.

Barriers and explanatory mechanisms in diagnostic delay in four cancers - A health-care disparity?

Introduction:

Most cancer disparities research has traditionally focused on two key outcomes, access to appropriate treatment and survival, but they do not encompass important aspects of patient-centered care such as the timeliness of diagnosis and treatment. Prolonged time intervals between symptom onset and treatment initiation increase the risk of poorer clinical outcomes and are associated with worse patient experience of subsequent cancer care. This study aims to assess the delay from symptom onset to the start of definitive treatment and to identify the possible contributory factors and its impact on response in cancers of head and neck, breast, cervix, and lung.

Materials and Methods:

This was a retrospective study of patients enrolled between 2015 and 2017. A questionnaire was filled in about socioeconomic aspects, patient history, tumor data, professionals who evaluated the patients, and the respective time delays. Statistical test included Mann–Whitney U test, univariate and multivariate test, and one-way ANOVA to evaluate the correlations.

Results:

Stage migration was significant with patient delay (P < 0.01). In head and neck squamous cell carcinoma (HNSCC) and Carcinoma lung, a significant correlation was found between referral delay and residence (P < 0.01) and treatment delay and reason for referral (HNSCC only) (P = 0.04). Referral delay and treatment delay were correlated to response in breast and cervix, respectively (P < 0.01).

Conclusion:

Social awareness, regularly updating primary care physicians about alarming symptoms of cancer, developing guidelines to identify these symptoms, promoting continuity of care, and enabling access to specialist expertise through prompt referral should all help prevent delays in cancer diagnosis.

Explaining Racial Disparities in Surgically Treated Head and Neck Cancer

OBJECTIVES/HYPOTHESIS

To assess the causative factors that contribute to racial disparities in head and neck squamous cell carcinoma (HNSCC) and establish the role of hospital factors in racial disparities.

STUDY DESIGN

Retrospective database analysis.

METHODS

Patients with surgically treated HNSCC were identified using the National Cancer Database (2004-2014). Logistic and proportional-hazard regression models were used to characterize the factors that contribute to racial disparities. Differences in quality of care received were compared among black and white patients using previously validated metrics.

RESULTS

We identified 69,186 eligible patients. Black patients had a 48% higher mortality than white patients (HR 1.48; 95% confidence interval [CI], 1.41-1.54). Black patients had a lower mean quality score (67.6%; 95% CI, 66.8%-69.4%) compared with white patients (71.2%: 95% CI, 71.0%-71.4%) for five quality metrics. After adjusting for differences in patient, oncologic, and hospital factors we were able to explain 60% of the excess mortality for black patients. Oncologic factors at presentation accounted for 57.7% of observed mortality differences, whereas hospital characteristics and quality of care accounted for 11.5%. After adjusting for these factors, black patients still had a 19% higher mortality (HR 1.19; 95% CI, 1.14-1.24).

CONCLUSIONS

Oncologic factors at presentation are a major contributor to racial disparities in outcomes for HNSCC. Hospital factors, such as quality, volume, and safety-net status, constitute a minor factor in the mortality difference. Resolving existing disparities will require detecting head and neck cancer at an earlier stage and improving the quality of care for black patients.

LEVEL OF EVIDENCE

3. Laryngoscope, 131:1053-1059, 2021.

Follow-Up Phone Interviews and Attendance Motivation From A Free Head and Neck Cancer Screening

INTRODUCTION

Head and Neck Cancer Awareness and Screening Programs (HNCASP) are popular community outreach events hosted by academic and community otolaryngology departments. However, long-term follow-up of participants is lacking.

PATIENTS AND METHODS

Participants of a HNCASP held at an academic cancer center prospectively filled out demographic and risk factor surveys followed by HNC screening examination. A phone interview was conducted for participants between 2012 and 2016 with suspicious findings to assess outcomes.

RESULTS

Participants were largely Caucasian, female, and had health insurance, reflecting the setting at an academic medical center. Despite this, there were 156 (16.8%) positive screenings; 47 of these completed follow up interviews. Twelve (1.1% of all participants) cancer cases were confirmed.

DISCUSSION

A significant proportion of HNCASP participants benefited from this screening opportunity. Education regarding HNC is the primary benefit and motivational factor for attendance of HNCASPs, although a significant subset of patients was identified that needed follow-up, and several cancers were detected.

Características clínicas y administrativas que se relacionan con el retraso en el diagnóstico y tratamiento de los pacientes con cáncer de cabeza y cuello

Introducción. En Colombia, el diagnóstico de los tumores de cabeza y cuello es tardío, lo cual aumenta la mortalidad, las secuelas estéticas y funcionales, y los costos para el sistema de salud. Actualmente, hay poca información sobre los factores que retrasan el diagnóstico y tratamiento de los pacientes con cáncer de cabeza y cuello. Métodos. Se trata un estudio transversal y analítico. Como referencia, se utilizó el cálculo de muestras para una población finita con un nivel de confianza del 95 % y un margen de error del 5 %, para un total de 159 pacientes con diagnóstico de cáncer de cabeza y cuello atendidos en la Clínica Vida de Medellín, entre los años 2016 y 2017. Resultados. Se evaluaron 146 pacientes. Los síntomas más frecuentes por los que consultaron fueron masa cervical y disfonía. Solo el 53,4 % de los pacientes buscó atención médica inmediata ante la presencia del síntoma. De aquellos que no la buscaron, la causa más frecuente fue la creencia de que el síntoma desaparecería espontáneamente. Discusión. Con base en los resultados obtenidos, se puede concluir que el síntoma de presentación juega un papel importante para que el paciente decida buscar o no buscar atención médica inmediata. El síntoma de presentación y el vivir en el área rural, retrasan el tiempo transcurrido entre la aparición del síntoma y la primera valoración por un médico de atención primaria. Los factores que se asociaron al retraso entre el diagnóstico y el inicio del tratamiento, fueron la seguridad social y el haber presentado tos como síntoma inicial.

Patterns of symptoms possibly indicative of cancer and associated help-seeking behaviour in a large sample of United Kingdom residents-The USEFUL study

BACKGROUND

Cancer awareness campaigns aim to increase awareness of the potential seriousness of signs and symptoms of cancer, and encourage their timely presentation to healthcare services. Enhanced understanding of the prevalence of symptoms possibly indicative of cancer in different population subgroups, and associated general practitioner (GP) help-seeking behaviour, will help to target cancer awareness campaigns more effectively.

AIM

To determine: i) the prevalence of 21 symptoms possibly indicative of breast, colorectal, lung or upper gastrointestinal cancer in the United Kingdom (UK), including six 'red flag' symptoms; ii) whether the prevalence varies among population subgroups; iii) the proportion of symptoms self-reported as presented to GPs; iv) whether GP help-seeking behaviour varies within population subgroups.

METHODS

Self-completed questionnaire about experience of, and response to, 25 symptoms (including 21 possibly indicative of the four cancers of interest) in the previous month and year; sent to 50,000 adults aged 50 years or more and registered with 21 general practices in Staffordshire, England or across Scotland.

RESULTS

Completed questionnaires were received from 16,778 respondents (corrected response rate 34.2%). Almost half (45.8%) of respondents had experienced at least one symptom possibly indicative of cancer in the last month, and 58.5% in the last year. The prevalence of individual symptoms varied widely (e.g. in the last year between near zero% (vomiting up blood) and 15.0% (tired all the time). Red flag symptoms were uncommon. Female gender, inability to work because of illness, smoking, a history of a specified medical diagnosis, low social support and lower household income were consistently associated with experiencing at least one symptom possibly indicative of cancer in both the last month and year. The proportion of people who had contacted their GP about a symptom experienced in the last month varied between 8.1% (persistent cough) and 39.9% (unexplained weight loss); in the last year between 32.8% (hoarseness) and 85.4% (lump in breast). Nearly half of respondents experiencing at least one red flag symptom in the last year did not contact their GP about it. Females, those aged 80+ years, those unable to work because of illness, ex-smokers and those previously diagnosed with a specified condition were more likely to report a symptom possibly indicative of cancer to their GP; and those on high household income less likely.

CONCLUSION

Symptoms possibly indicative of cancer are common among adults aged 50+ years in the UK, although they are not evenly distributed. Help-seeking responses to different symptoms also vary. Our results suggest important opportunities to provide more nuanced messaging and targeting of symptom-based cancer awareness campaigns.

Factors associated with delay in presentation among patients for oral cancer

Aim: This study aimed to determine factors that influence delay in presentation among oral cancer patients. Materials & methods: A cross-sectional study with 128 Oral cancer patients receiving treatment from the Hospital of Stomatology, at Jilin University, in China, was conducted. Results: A total of 78 patients delayed seeking treatment for more than 3 weeks after noticing symptoms of oral anomaly. Patients who were male, farmers (Odds ratio [OR] = 2.617; 95% CI: 1.90–3.64), or currently smoking (OR = 4.651; 95% CI: 1.21–9.46), were more likely to delay. Patients alerted to the problem at a physical exam had much lower risk of delay than patients who discovered the disease independently (OR = 0.029; 95% CI: 0.01–0.30). Higher coping style scores (OR = 0.747; 95% CI: 0.47–1.18) and oral cancer knowledge scores (OR = 0.886; 95% CI: 0.60–2.01) were significantly correlated with shorter delays. Conclusion: Delay in presentation may be achieved through regular oral health screening and improved public education about factors influencing delay.

Knowledge and Health Seeking Behaviour of Breast Cancer Patients in Ghana

Background

Breast cancer is a major contributor to cancer-related deaths among women worldwide, despite the numerous measures employed to prevent and manage the disease. This study explored the knowledge and health seeking behaviour of breast cancer patients at the Komfo Anokye Teaching Hospital.

Methods

A descriptive cross-sectional study was conducted at Komfo Anokye Teaching Hospital in Kumasi, Ghana, from June 2014 to July 2014. Thirty-five participants were purposively selected. The responses to questions about their experiences with breast cancer were determined using indepth interviews. Transcripts were coded and analysed using NVIVO version 10.0.

Results

Participants' knowledge about signs and symptoms of breast cancer after their diagnosis was high but low for risk factors. Screening for breast cancer through self-breast examination was infrequently performed prior to their diagnosis. The patients' first point of care was generally health facilities. Some patients reported late due to misinterpretation of signs and symptoms, cultural influences and fear of losing their breast to surgery, physician delay, health providers' laxity, and disinterest in breast cancer. Men, for example, husbands, decide on where and when breast cancer patients go for treatment.

Conclusion

There is poor knowledge of the risk factors for developing breast cancer. Patients resorted to the hospital as first options for cure but were generally delayed in doing so. There is the need to create awareness about breast cancer among the general population.

Causes for delay before specialist consultation in head and neck cancer

BACKGROUND

Head and neck cancers are often diagnosed at a late stage, thus resulting in a generally poor prognosis. This is partly attributable to patients' hesitancy in seeking treatment. However, the length and causes of these patient delays remain relatively unknown.

MATERIAL AND METHODS

We included all new head and neck cancer patients treated at our tertiary care center between 2016 and 2017. Using a patient questionnaire, we collected data on patients' symptoms and other factors related to seeking medical care, and recorded both patient- and primary health care-related delays. We then compared the data collected from these patients to patient and tumor characteristics collected from hospital records, and analyzed various causes for delay before a specialist consultation to the Department of Otorhinolaryngology - Head and Neck Surgery.

RESULTS

Among the patients (n = 142) in our study, the median patient delay was 35 d with 73% of patients seeking medical care within 3 months. In comparison, the median primary health-care delay was 20 d. Certain symptoms influenced patient delay. Hoarseness and breathing difficulties correlated with longer patient delay while patients with a lump on the neck had a shorter delay. Patient delay was associated with certain tumor-related factors such as the tumor site and the presence of regional metastases, which resulted in shorter patient delay. None of the patient-related factors appeared to impact delay. Important factors influencing primary health-care delay included the initial location visited and whether any follow-up visit was scheduled or not.

CONCLUSIONS

Although most patients sought medical advice without a major delay and were adequately referred, we found that long delays existed. Raising awareness of the symptoms of head and neck cancer among general population and health-care providers is probably the best way to get patients to curative treatment without delay.

Lifestyle, socioeconomic status and healthcare seeking among women with gynaecological cancer alarm symptoms: a combined questionnaire-based and register-based population study

OBJECTIVES

To determine the proportion of contacts to general practitioner (GP) with recent onset gynaecological cancer alarm symptoms (pelvic pain, postmenopausal bleeding, bleeding during intercourse or pain during intercourse) and to analyse the associations between lifestyle factors, socioeconomic status and GP contact for these symptoms.

DESIGN

Cross-sectional survey combined with data from national registers.

SETTING

The general Danish population.

PARTICIPANTS

A total of 25 866 non-pregnant women ≥20 years completed the survey. Women reporting at least one of four gynaecological alarm symptoms within the preceding 6 months form the study base (n=2957).

RESULTS

The proportion of women reporting GP contact ranged from 21.1% (pain during intercourse) to 32.6% (postmenopausal bleeding). Women aged 60+ years had higher odds of reporting GP contact for at least one of the four gynaecological cancer alarm symptoms compared with those aged 20-39 years (OR 2.56, 95% CI 1.69 to 3.89), and immigrants had higher odds of reporting GP contact for at least one of the symptoms (OR 1.56, 95% CI 1.13 to 2.15) compared with ethnic Danish individuals. Among those reporting postmenopausal bleeding and/or bleeding during intercourse, women in the age group 60+ years had higher odds of reporting GP contact compared with those aged 20-39 years (OR 2.79, 95% CI 1.33 to 5.87). A high educational level (>12 years) was positively associated with reporting GP contact for postmenopausal bleeding and/or bleeding during intercourse compared with a low educational level (<10 years) (OR 2.23, 95% CI 1.19 to 4.19). No associations were found with lifestyle factors.

CONCLUSIONS

Few women contacted their GP with recent onset gynaecological cancer alarm symptoms. Higher age, being immigrant and higher educational level increased the odds of GP contact. Future studies should explore the reasons for these findings as this may aid in prompting early diagnosis and thereby improve the prognosis of gynaecological cancer.

Psychosocial Distress and Distress Screening in Multidisciplinary Head and Neck Cancer Treatment

Psychosocial distress screening (DS) for cancer and head and neck cancer (HNC) patients is rapidly becoming the standard of care. DS is of particular importance for patients with HNC, given their heightened incidence of distress, depression, anxiety, suicide, quality of life impacts, and negative medical outcomes. In the absence of DS, distress is frequently missed in oncology settings. However, when identified, distress is highly responsive to treatment, with cognitive behavioral and behavioral medicine interventions demonstrating evidence of efficacy. Multidisciplinary HNC teams are uniquely positioned to implement effective DS programs and treatment tailored to HNC patients' psychological and medical vulnerabilities.

Psychiatric disease in surgically treated colorectal cancer patients

BACKGROUND

Underlying psychiatric conditions may affect outcomes of surgical treatment for colorectal cancer (CRC) because of complex clinical presentation and treatment considerations. We hypothesized that patients with psychiatric illness (PSYCH) would have evidence of advanced disease at presentation, as manifested by higher rates of colorectal surgery performed in the presence of obstruction, perforation, and/or peritonitis (OPP-surgery).

MATERIALS AND METHODS

Using data from the 2007-2011 National Inpatient Sample, we identified patients with a diagnosis of CRC undergoing colorectal surgery. In addition to somatic comorbid conditions flagged in the National Inpatient Sample, we used the Clinical Classification Software to identify patients with PSYCH, including schizophrenia, delirium/dementia, developmental disorders, alcohol/substance abuse, and other psychiatric conditions. Our study outcome was OPP-surgery. In addition to descriptive analysis, we conducted multivariable logistic regression analysis to analyze the independent association between each of the PSYCH conditions and OPP-surgery, after adjusting for patient demographics and somatic comorbidities.

RESULTS

Our study population included 591,561 patients with CRC and undergoing colorectal cancer surgery, of whom 60.6% were aged 65 years or older, 49.4% were women, and 6.3% had five or more comorbid conditions. Then, 17.9% presented with PSYCH. The percent of patients undergoing OPP-surgery was 13.9% in the study population but was significantly higher for patients with schizophrenia (19.3%), delirium and dementia (18.5%), developmental disorders (19.7%), and alcohol/substance abuse (19.5%). In multivariable analysis, schizophrenia, delirium/dementia, and alcohol/substance abuse were each independently associated with increased rates of OPP-surgery.

CONCLUSIONS

Patients with PSYCH may have obstacles in receiving optimal care for CRC. Those with PSYCH diagnoses had significantly higher rates of OPP-surgery. Additional evaluation is required to further characterize the clinical implications of advanced disease presentation for patients with PSYCH diagnoses and colorectal cancer.

Paradigm shift in head and neck oncology patient management

Objective

This article describes a paradigm shift in what is considered to be good care for patients living with and after (head and neck) cancer. HNO patients often experience severe and difficult physical and psychosocial problems due to the nature and location of the disease. Many disciplines are involved in their treatment, so their voice is only one amongst many others in the decision making process. For this patient group it seems complicated to put the concept of Shared Decision Making into practice. As a step in this direction, patient reported outcomes which ask patients to select the disconcerting issues and symptoms can be used as a basis for referral, supportive care and treatment decision making. We need to provide more tailored and personalized information that is specific to individual circumstances, preferences and concerns and focuses more on the impact of treatment and access to help and support. Follow up of these patients should be concentrated on both medical and emotional aspects.

Practice implications

A shift in the way caregivers provide their information contributes to a more profound involvement of patients in treatment decisions.

Assessment of time intervals in the pathway to oral cancer diagnosis in north-westerm Spain. Relative contribution of patient interval

BACKGROUND

Despite continuous advances in diagnosis and therapy, oral cancers are mostly diagnosed at advanced stages with minor survival improvements in the last two decades. Both phenomena have been attributed to delays in the diagnosis. This study aims at quantifying the time elapsed until definitive diagnosis in these patients and the patient interval's contribution.

MATERIAL AND METHODS

A hospital-based, ambispective, observational study was undertaken on incident cases with a pathological diagnosis of oral squamous cell carcinoma recruited during 2015 at the Oral and Maxillofacial Surgery services of CHUAC (A Coruña) and POVISA (Vigo) hospitals.

RESULTS

74 consecutive oral cancer patients (59.5% males; median age: 65.0 years (IQ:57-74)) were studied. Most cases (52.7%; n=39) were at advanced stages (TNM III-IV) at diagnosis. The period since first sign/symptom until the patient seeks health care was the longest interval in the pathway to diagnosis and treatment (median: 31.5 days; IQR= 7.0 - 61.0) and represents >60% of the interval since symptom onset until referral to specialised care (pre-referral interval). The average interval assigned to the patient resulted to be relatively larger than the time elapsed since the patient is seen at primary care until a definitive diagnosis is reached (diagnostic interval). Median of the referral interval for primary care professionals: 6.5 days (IQR= 0.0 - 49.2) and accounts for 35% (19% - 51%) of the diagnostic interval.

CONCLUSIONS

The patient interval is the main component of the pathway to treatment since the detection of a bodily change until the definitive diagnosis. Therefore, strategies focused on risk groups to shorten this interval should be implemented in order to ease an early diagnosis of symptomatic oral cancer.

Impact of waiting time on nodal staging in head and neck squamous-cell carcinoma treated with radical intensity modulated radiotherapy

BACKGROUND AND PURPOSE

To evaluate the influence of delays for radiotherapy on survival, recurrence and upstaging for head and neck squamous-cell carcinoma (HNSCC) with no nodal involvement treated with intensity modulated radiotherapy (IMRT).

MATERIAL AND METHODS

This retrospective study included 63 consecutive patients with HNSCC located in the pharynx and larynx and treated with exclusive IMRT with or without chemotherapy. Survival, loco-regional or distant failure and upstaging were analyzed according to the waiting time.

RESULTS

Mean waiting time for treatment was 62.5 days for the hypopharynx subgroup (range = 37-102), 63 days for the larynx subgroup (range = 19-128) and 58.5 days for the oropharynx subgroup (range = 29-99) (p = 0.725). Nine patients (14%) experienced upstaging. Loco-regional or distant failure occurred in 18 patients. Beyond a delay of 50 days, 19% of patients had local failure, 17% nodal recurrence and 11% distant failure. Within a delay of 50 days, no nodal or distant failure was observed and only 1 patient experienced local recurrence. Upstaging and overall survival were not significantly affected by an increased waiting time.

CONCLUSION

For N0 patients treated with IMRT for HNSCC, waiting time around 50 days after the diagnosis was not significantly associated with an excessive risk of upstaging or recurrence.

The Impact of Preexisting Mental Health Disorders on the Diagnosis, Treatment, and Survival among Lung Cancer Patients in the U.S. Military Health System

BACKGROUND

Higher cancer-related mortality has been observed among people with mental health disorders than in the general population. Both delay in diagnosis and inadequate treatment due to health care access have been found to explain the higher mortality. The U.S. Military Health System (MHS), in which all beneficiaries have equal access to health care, provides an ideal system to study this disparity where there are no or minimal barriers to health care access. This study assessed preexisting mental health disorders and stage at diagnosis, receipt of cancer treatment, and overall survival among patients with non-small cell lung cancer (NSCLC) in the U.S. MHS.

METHODS

The study used data from the linked database from the Department of Defense's Central Cancer Registry and the MHS Data Repository (MDR). The study subjects included 5,054 patients with histologically confirmed primary NSCLC diagnosed between 1998 and 2007.

RESULTS

Patients with a preexisting mental disorder did not present with more advanced disease at diagnosis than those without. There were no significant differences in receiving cancer treatments between the two groups. However, patients with a mental health disorder had a higher mortality than those without [adjusted HR, 1.11; 95% confidence interval (CI), 1.03-1.20].

CONCLUSIONS

Poor survival in NSCLC in patients with a preexisting mental health disorder is not necessarily associated with delay in diagnosis and/or inadequate cancer treatment.

IMPACT

This study contributes to the current understanding that health care access may not be sufficient to explain the poor survival among patients with NSCLC with preexisting mental health disorders. Cancer Epidemiol Biomarkers Prev; 25(12); 1564-71. ©2016 AACR.

Key points and time intervals for early diagnosis in symptomatic oral cancer: a systematic review

The aim of this study was to identify key points and time intervals in the patient pathway to the diagnosis of oral cancer, from the detection of a bodily change to the start of treatment. A systematic search of three databases was performed by two researchers independently. Articles reporting original data on patients with symptomatic primary oral or oropharyngeal squamous cell carcinoma that was pathologically confirmed were included. These articles had to include an outcome variable of 'diagnostic delay', 'time interval', or 'waiting time to diagnosis', or report time intervals from first symptom to treatment. Furthermore, the outcome variable had to have a clearly defined start point and end point, with the time measurement presented as a continuous or categorical variable. A total of 1175 reports were identified; 28 articles on oral cancer studies and 13 on oral and oropharyngeal cancer studies were finally included. These papers showed poor quality in terms of questionnaire validation, acknowledgement of biases influencing time-point measurements, and strategies for verification of patient self-reported data. They also showed great heterogeneity. The review findings allowed the definition of key points and time intervals within the Aarhus framework that may better suit the features of the diagnostic process of this neoplasm, particularly when assessing the impact of waiting time to diagnosis.

Lifestyle factors and contact to general practice with respiratory alarm symptoms-a population-based study

Background

A prerequisite for early lung cancer diagnosis is that individuals with respiratory alarm symptoms (RAS) contact a general practitioner (GP). This study aims to determine the proportion of individuals in the general population who contact a GP with RAS and to analyse the association between lifestyle factors and contact to GPs with RAS.

Methods

A web-based survey of 100 000 individuals randomly selected from the Danish Civil Registration System. Items regarding experience of RAS (prolonged coughing, shortness of breath, coughing up blood, and prolonged hoarseness), GP contacts, and lifestyle factors (smoking status, alcohol intake, and body mass index) were included.

Results

In total 49 706 (52.5 %) individuals answered the questionnaire. Overall 7870 reported at least one respiratory alarm symptom, and of those 39.6 % (3 080) had contacted a GP. Regarding specific symptoms, the proportion of individuals that had contacted a GP varied from 27.4 % (prolonged hoarseness) to 47.9 % (shortness of breath). Being a woman and increasing age were significantly associated with a higher proportion of GP contacts. For both genders, current smoking and alcohol intake were significantly associated with lower odds of contacting a GP.

Conclusion

Among individuals with RAS, less than one-half contacted a GP. Gender, age, smoking status, and alcohol intake significantly influenced whether individuals with RAS contacted a GP.

Trial registration

The project has been approved by the Danish Data Protection Agency (journal no. 2011-41-6651).

Impact of delay in the diagnosis and treatment of head and neck cancer

Introduction

Head and neck tumors can be easily recognized through clinical evaluation. However, they are often diagnosed at advanced stages.

Objective

To evaluate the delay from the patient's initial symptoms to the definitive treatment.

Methods

Retrospective study of patients enrolled in 2011 and 2012. A questionnaire was filled in about socioeconomic aspects, patient history, tumor data, professionals who evaluated the patients, and the respective time delays.

Results

The following time delay medians were observed: ten months between symptom onset and the first consultation; four weeks between the latter and the first consultation with a specialist; four weeks between the specialist consultation and diagnosis attainment; and 12 weeks between diagnosis and the start of treatment.

Conclusions

Most head and neck tumors are diagnosed at advanced stages, due to patient and health care factors.

Health advisor facilitated mouth care regime for patients with head and neck cancers undergoing intensity-modulated radiotherapy

Aim

To develop a regime of care for patients with head and neck cancers undergoing intensity-modulated radiotherapy (IMRT), with the support of a health advisor (HA) and temporary access to the mouth care product Caphosol™.

Materials and methods

A HA was temporarily employed to assess, monitor and refer patients as appropriate and ensure patients received and utilised supplies of Caphosol™. A retrospective audit was undertaken to provide a gap analysis of current service. The data were used to develop a pro forma for documenting assessments and monitoring lifestyle factors for IMRT patients. Assessments referrals and compliance, plus hospital admissions owing to treatment-related issues, were documented during the baseline audit and the temporary HA service and provision of Caphosol™.

Results

The presence of a HA facilitated 100% compliance with appropriate assessments, referrals and adherence to treatment. The data suggests that the additional provision of Caphosol™ may have reduced levels of mucositis and associated pain.

Conclusion

It is recommended that a HA role be established within radiotherapy departments to facilitate lifestyle assessments, referrals and compliance with positive behaviour changes (e.g., stopping smoking). The use of Caphosol™ as a routine part of mouth care regime for IMRT patients also warrants further investigation.

Early oral cancer diagnosis: The Aarhus statement perspective. A systematic review and meta-analysis

BACKGROUND

Mortality is linked to diagnostic intervals in certain cancers. As symptom perception is conditioned by tumor site, a specific study on oral cancer is needed.

METHODS

This study's inclusion criteria were original data, symptomatic primary oral squamous cell carcinoma, and exposure of interest, diagnostic interval, or diagnostic delay. The outcome of interest was survival and disease stage. A meta-analysis was undertaken to investigate the relationship between intervals to diagnosis, TNM classification, and survival in oral cancer.

RESULTS

Regarding referral delay, the results present no heterogeneity and showed a risk increase in mortality of 2.48 (range = 1.39-4.42). The larger the diagnostic delay, the more advanced the stage at diagnosis. High quality studies reveal a higher risk increase than low quality studies (odds ratio [OR] = 2.44; 95% confidence interval [CI] = 1.36-4.36 vs OR = 1.53; 95% CI = 1.26-1.86).

CONCLUSION

A longer time interval from first symptom to referral for diagnosis is a risk factor for advanced stage and mortality of oral cancer. © 2015 Wiley Periodicals, Inc. Head Neck 38: E2182-E2189, 2016.

The effect of pre-existing mental health comorbidities on the stage at diagnosis and timeliness of care of solid tumor malignances in a Veterans Affairs (VA) medical center

There are limited data on the impact of mental health comorbidities (MHC) on stage at diagnosis and timeliness of cancer care. Axis I MHC affect approximately 30% of Veterans receiving care within the Veterans Affairs (VA) system. The purpose of this study was to compare stage at diagnosis and timeliness of care of solid tumor malignancies among Veterans with and without MHC. We performed a retrospective analysis of 408 charts of Veterans with colorectal, urothelial, and head/neck cancer diagnosed and treated at VA Connecticut Health Care System (VACHS) between 2008 and 2011. We collected demographic data, stage at diagnosis, medical and mental health co-morbidities, treatments received, key time intervals, and number of appointments missed. The study was powered to assess for stage migration of 15–20% from Stage I/II to Stage III/IV. There was no significant change in stage distribution for patients with and without MHC in the entire study group (p = 0.9442) and in each individual tumor type. There were no significant differences in the time intervals from onset of symptoms to initiation of treatment between patients with and without MHC (p = 0.1135, 0.2042 and 0.2352, respectively). We conclude that at VACHS, stage at diagnosis for patients with colorectal, urothelial and head and neck cancers did not differ significantly between patients with and without MHC. Patients with MHC did not experience significant delays in care. Our study indicates that in a medical system in which mental health is integrated into routine care, patients with Axis I MHC do not experience delays in cancer care.

Determinants of patient delay in doctor consultation in head and neck cancers (Protocol DEREDIA)

INTRODUCTION

Reducing the time between the onset of the first symptoms of cancer and the first consultation with a doctor (patient delay) is essential to improve the vital prognosis and quality of life of patients. Longer patient delay is linked to the already known sociodemographic, socioeconomic, socioeducational, sociocultural and socioprofessional factors. However, recent data suggest that some sociocognitive and emotional determinants may explain patient delay from a complementary point of view. The main objective of this study is to assess whether, in head and neck cancer, patient delay is linked to these sociocognitive and emotional factors, in addition to previously known factors.

METHODS AND ANALYSIS

We intend to include in this study 400 patients with a not yet treated head and neck cancer diagnosed in one of six health centres in the North of France region. The main evaluation criterion is 'patient delay'. Sociocognitive, emotional, medical, sociodemographic, socioeconomic, educational, professional and geographic factors will be assessed by means of (1) a case report form, (2) a questionnaire completed by the clinical research associate together with the patient, (3) a questionnaire completed by the patient and (4) a recorded semidirective interview of the patient by a psychologist (for 80 patients only). The collected data will be analysed to underline the differences between patients who consulted a doctor earlier versus those who consulted later.

ETHICS

The study has obtained all the relevant authorisations for the protection of patients enrolled in clinical trials (CCTIRS, CCP, CNIL), does not involve products mentioned in article L.5311-1 of the French Code of Public Health, and does not imply any changes in the medical care received by the patients. The study began in October 2012 and will end in June 2015.

TRIAL REGISTRATION

ID-RCB 2012-A00005-38.

How might healthcare systems influence speed of cancer diagnosis: a narrative review

Striking differences exist in outcomes for cancer between developed countries with comparable healthcare systems. We compare the healthcare systems of 3 countries (Denmark, Norway, Sweden), 3 UK jurisdictions (England, Wales and Northern Ireland), 3 Canadian provinces (British Columbia, Manitoba, Ontario) and 2 Australian states (New South Wales, Victoria) using a framework which assesses the possible contribution of primary care systems to a range of health outcomes, drawing on key characteristics influencing population health.

For many of the characteristics we investigated there are no significant differences between those countries with poorer cancer outcomes (England and Denmark) and the rest. In particular, regulation, financing, the existence of patient lists, the GP gatekeeping role, direct access to secondary care, the degree of comprehensiveness of primary care services, the level of cost sharing and the type of primary care providers within healthcare systems were not specifically and consistently associated with differences between countries. Factors that could have an influence on patient and professional behaviour, and consequently contribute to delays in cancer diagnosis and poorer cancer outcomes in some countries, include centralisation of services, free movement of patients between primary care providers, access to secondary care, and the existence of patient list systems.

It was not possible to establish a causal correlation between healthcare system characteristics and cancer outcomes. Further studies should explore in greater depth the associations between single health system factors and cancer outcomes, recognising that in complex systems where context is all-important, it will be difficult to establish causal relationships. Better understanding of the interaction between healthcare system variables and patient and professional behaviour may generate new hypotheses for further research.

•

We examined cancer outcomes in six developed countries with comparable healthcare systems.

•

Clear differences exist in cancer outcomes between countries with comparable healthcare systems.

•

Centralisation, movement of patients between providers, access to secondary care, and list systems appear influential.

•

Better understanding of interactions between system variables and patient and professional behaviour may improve outcomes.

Total delay for treatment among cancer patients: a theory-guided survey in China

PURPOSE

This study aimed at exploring treatment delay (TD) among cancer patients in China with an attempt to develop a practical methodology facilitating frontline Chinese clinicians in promoting earlier cancer diagnosis and treatment.

MATERIALS AND METHODS

The study comprised framework development, qualitative interviews and paired factor rating. Framework development utilized systematic literature review, soft systems thinking and consensus groups. Qualitative interviews employed a checklist of open questions soliciting information about all the domains included the framework from cancer patients drawn via stratified randomized sampling of inpatients at 10 hospitals in Hefei, China. Paired factor rating used a self-developed computer aid and the interviewed patients as referring cases to weigh the relative importance of the factors listed in the framework in terms of their contributions to specific components of total delay (TD).

RESULTS

a) A conceptual framework was proposed consisting of a 6-step path to TD and 36 category determinants. b) A total of 227 patients were interviewed; their TD was 267.3 mean or 108 median days ranging from 0 to 2475 days; average appraisal, illness, behavioral, preparation and treatment delay accounted for 52.1%, 9.4%, 0.30%, 8.8% and 29.4% of the TD respectively. Individual side factors were rated substantially more important than environmental side factors (60% vs. 40%); most influential TD factors included cancer symptoms, overall health, family relations and knowledge about cancer and health.

CONCLUSIONS

The framework proposed together with the interviewing and rating approaches used provide a potential new methodology for understanding cancer patients' TD and promoting earlier cancer treatment.

Patient-related delay in presentation for cutaneous squamous cell carcinoma. A cross-sectional clinical study

BACKGROUND

Delayed diagnosis of squamous cell carcinoma (SCC) increases recurrence, metastatic potential, and management costs. This study aims to identify risk factors of patient-related delayed presentation in cutaneous SCC.

PATIENTS AND METHODS

A total of 513 patients, who first sought care for cutaneous lesions that were subsequently removed and histologically confirmed as SCCs, were included. Attitude to symptoms, psychosocial profile, and reasons for delayed presentation were obtained via a structured questionnaire-based interview. First presentation > 3 months from the onset of symptoms was considered as delayed.

RESULTS

Mean presentation time was 3.90 ± 2.05 months, while 186 patients delayed presentation. Multivariate logistic regression analysis revealed that serious co-morbidity (p = 0.003), low education level (p < 0.001), non-recognition of the seriousness of symptoms (p < 0.001), a 'wait and see' attitude (p < 0.001), and fatalism (p = 0.005) were independent determinants of significantly higher risk for delayed presentation. In contrast, female sex (p = 0.006), new lesion (p = 0.012), accessible topography (p = 0.019), size increase (p = 0.002), color change (p = 0.017), non-healing wound (p = 0.048), and presence of social support/advice (p < 0.001) were independent determinants significantly associated with early presentation.

CONCLUSION

Recognition of symptom seriousness and elimination of factors hindering self-referral may increase awareness and promote early patient presentation and diagnosis of cutaneous SCC.

Patient delay in colorectal cancer patients: associations with rectal bleeding and thoughts about cancer

Rectal bleeding is considered to be an alarm symptom of colorectal cancer. However, the symptom is seldom reported to the general practitioner and it is often assumed that patients assign the rectal bleeding to benign conditions. The aims of this questionnaire study were to examine whether rectal bleeding was associated with longer patient delays in colorectal cancer patients and whether rectal bleeding was associated with cancer worries. All incident colorectal cancer patients during a 1-year period in the County of Aarhus, Denmark, received a questionnaire. 136 colorectal cancer patients returned the questionnaire (response rate: 42%). Patient delay was assessed as the interval from first symptom to help-seeking and was reported by the patient. Patients with rectal bleeding (N = 81) reported longer patient intervals than patients without rectal bleeding when adjusting for confounders including other symptoms such as pain and changes in bowel habits (HR = 0.43; p = 0.004). Thoughts about cancer were not associated with the patient interval (HR = 1.05; p = 0.887), but more patients with rectal bleeding reported to have been wondering if their symptom(s) could be due to cancer than patients without rectal bleeding (chi² = 15.29; p<0.001). Conclusively, rectal bleeding was associated with long patient delays in colorectal cancer patients although more patients with rectal bleeding reported to have been wondering if their symptom(s) could be due to cancer than patients without rectal bleeding. This suggests that assignment of symptoms to benign conditions is not the only explanation of long patient delays in this patient group and that barriers for timely help-seeking should be examined.

Perceptions of cancer as a death sentence: prevalence and consequences

Research suggests that perceiving cancer as a death sentence is a critical determinant of health care-seeking behaviors. However, there is limited information regarding the prevalence of this perception in the US population. Cross-sectional analysis of data (n = 7674 adults) from the 2007-2008 administration of the nationally representative Health Information National Trends Survey (HINTS 3) was performed. A majority (61.6%) of respondents perceived cancer as death sentence, and more than one-third (36%) of respondents reported that they avoid seeing their physicians. In the adult US population, perceiving cancer as a death sentence is common and is associated with education level and avoidance of physicians.

Coping strategies and patient delay in patients with cancer

This study examined associations between avoidance and approach coping and patient delay in cancer patients (N = 1024). Approach coping was associated with short appraisal intervals (time from symptom discovery to recognition of symptom seriousness). Avoidance coping was associated with long appraisal intervals when adjusting for covariates. Help-seeking intervals (time from recognition of symptom seriousness to contact to general practitioner) were only associated with approach coping and only when adjusting for the influence of covariates. The results revealed a complex relationship between coping and patient delay and supported that normal processing of health threats implies avoidance and approach coping strategies.

Styles of coping with stress of cancer in patients treated with radiotherapy and expectations towards medical staff - Practical implications

BACKGROUND

It is essential to adjust oncological treatment to medical procedures but also to the expectations of patients themselves. Expectations of patients may depend on the way of coping with the stress of cancer. Many researchers have dealt with this issue. However, it is difficult to find studies concerning relations between the styles of coping and expectations of patients towards medical staff.

AIM

To demonstrate the relationship between the style of coping with stress of cancer shown by patients undergoing radiotherapy at the Greater Poland Cancer Centre and the nature of their expectations towards the medical staff, and to present work of the Clinical Psychology Unit in response to the expectations of patients.

MATERIALS AND METHODS

Questionnaire survey. The respondents filled in a questionnaire consisting of a patient request form (PRF), the mini-mental adjustment to cancer scale (Mini-MAC), and personal data. Obtained results were subjected to statistical analysis.

RESULTS

SIGNIFICANT ASSOCIATIONS: the expectation to have the disease explained is associated with anxious preoccupation, fighting spirit, helplessness-hopelessness; the expectation of emotional support is associated with anxious preoccupation and helplessness-hopelessness; and the expectation of information on examinations and treatment is associated with anxious preoccupation and helplessness-hopelessness.

CONCLUSIONS

Expectations of patients undergoing radiotherapy in the Greater Poland Cancer Centre towards the medical staff depend on their styles of coping with the stress of cancer.

Does the organizational structure of health care systems influence care-seeking decisions? A qualitative analysis of Danish cancer patients' reflections on care-seeking

OBJECTIVE

The absence of a more significant improvement in cancer survival in countries such as the UK and Denmark may be partly rooted in delayed care-seeking among cancer patients. Past research on patient delay has mainly focused on patient characteristics (e.g. sociodemographic and psychological factors and symptom recognition) as causes of delayed care-seeking, while few studies have examined how the organizational structure of health care systems may influence patients' reflections on seeking care. The aim of this study was to explore this relationship.

DESIGN

The analysis presented is based on semi-structured interviews with 30 cancer patients and their families.

RESULTS

The article raises two hypotheses on the relationship between structural elements of a health care system and people's reflections on seeking health care: (1) Gatekeeping introduces an asymmetrical relationship between the patient and the GP which potentially results in self-restricting care-seeking, (2) Continuity in the doctor-patient relationship may negatively influence patient reflections on access to health care, as the focus shifts from the medical issues of the consultation to reflections on how to properly interact with the GP and the system in which she/he is situated.

CONCLUSION

It is concluded that these hypotheses form a sound basis for further primary care research on how the organizational structure of health care systems influences patient reflections on access to medical care.

Calming panic states in the Mould Room and beyond: A pilot complementary therapy head and neck cancer service

Purpose: The service was piloted in response to requests for assistance with patients experiencing severe anxiety undergoing head and neck radiotherapy. This paper describes the aims of the service, interventions provided and the recorded responses of patients to the support given.

Data: Information about who referred, patient demographics, the interventions provided and patient feedback (n = 112) was extracted from treatment records over a 15-month period.

Findings: All referred patients successfully completed procedures and treatment. About 43 patients voluntarily disclosed past trauma, for example, sexual abuse, assault, childhood trauma, which they judged to have been linked to their claustrophobic responses. Advice and support was given to 40 patients also referred for smoking cessation; an additional three patients requested support when cravings returned.

Conclusion: There is a paucity of information about the extent of the distress triggered by radiotherapy procedures and what interventions could be offered in practice. Further work is required to include an economic assessment and longer term effects on patient compliance with treatment and smoking cessation. Training needs for complementary therapists and radiotherapy staff at this centre were also identified; these are being addressed.