Patient factors associated with delay in primary care among patients with head and neck carcinoma: a case-series analysis

A descriptive study on diagnostic timelines, and factors influencing delayed diagnosis among adult head and neck cancer patients at Uganda cancer institute

BACKGROUND

Many patients with head and neck cancer (HNC) often present with advanced disease. This may result from delay in deciding to seek care, delay in reaching the healthcare facility and or delay in accessing care in the healthcare facility. We therefore set out to determine the time to definitive diagnosis and factors associated with delayed diagnosis among patients with HNC at the Uganda Cancer Institute (UCI).

METHODS

A cross-sectional study was conducted at UCI, patients with HNC were recruited. An interviewer administered questionnaire was used to collect data on sociodemographic factors and clinical characteristics, including timelines in months, from symptom onset to deciding to seek care, to reaching the health care facility and to definitive diagnosis. Multivariate Poisson regression analysis was used to calculate odds ratios (ORs) for the factors of association with delayed diagnosis.

RESULTS

We recruited 160 HNC patients, and 134 patients were analyzed. The median age was 49.5 years (IQR 26.5), 70% (94 of 134) were male, 48% (69 of 134) had below secondary school education, 49% (65 of 134) had a household income < 54 USD. 56% (76 of 134) were sole bread winners, 67% (89 of 134) had good access road condition to the nearest health unit and 70% (91 of 134) presented with tumor stage 4. Median time from onset of symptoms to definitive diagnosis was 8.1 months (IQR 15.1) and 65% (87 of 134) of patients had delayed diagnosis. Good access roads (aOR: 0.26, p = 0.006), secondary school education (aOR: 0.17, p = 0.038), and household income > 136 USD (aOR: 0.27, p = 0.043) were associated with lower odds of delayed diagnosis. Being the sole bread winner (aOR: 2.15, p = 0.050) increased the odds of delayed diagnosis.

CONCLUSION

Most of HNC patients (65%) at UCI had delayed diagnosis. A national care pathway for individuals with suspected HNC should be established and consider rotation of Ear, Nose and Throat surgeons to underserved regions, to mitigate diagnostic delay.

Questionnaire Survey to Identify the Medical Departments That Patients With Possible Head and Neck Cancer (HNC) Symptoms Tend to Choose

In the treatment of head and neck cancer (HNC), any delay in omit initiation worsens the overall prognosis. Thus, the early start of HNC treatment is crucial. Unfortunately, treatment delays persist in clinical practice. There are several possible reasons for this. One reason is that patients with HNC do not visit an ear, nose, and throat (ENT) doctor. This is because non-ENT doctors (e.g., general practitioners {GPs}) lack expertise in HNC and therefore may unrecognize it. Therefore, guiding patients with suspected HNC symptoms to an otorhinolaryngologist, an HNC specialist, is necessary. To determine the departments that patients with potential HNC symptoms tend to select, we administered a questionnaire survey to 140 participants. Fewer than 60% of respondents indicated they would consult an otorhinolaryngologist even when recognizing symptoms suggestive of HNC. Notably, a significantly low percentage of respondents mentioned they would consult an otorhinolaryngologist for neck masses. Public awareness of HNC symptoms, especially the association between a neck mass and HNC, is limited. The lack of understanding by the general public regarding the relationship between neck masses and HNC is a challenge to prompt initiation of treatment.

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.

Effects of ionizing radiation and different resin composites on shear strength of ceramic brackets: an in vitro study

Introduction:

Head and neck cancer is considered one of the most common types, and its treatment includes radiotherapy, which can trigger side effects and undesirable sequelae in the oral cavity and dental tissues.

Objective:

This study aimed to make an in vitro evaluation of the shear strength and failure mode of ceramic orthodontic brackets bonded with two different composites in enamel submitted to ionizing radiation.

Methods:

After the study was approved by the Research Ethics Committee, 60 healthy human premolars were selected and divided into two groups, based on the absence or presence of ionizing irradiation of the enamel. The fragments were thermocycled and then randomly subdivided into two subgroups, according to the composite used for bonding the ceramic brackets (Inspire Ice - Ormco) to the enamel (n = 15): Transbond XT composite (3M), and Light Bond composite (Reliance). After 24 hours, the specimens were submitted to the shear strength test, and the failure mode was analyzed using a stereomicroscope and confocal microscopy. The shear strength data were submitted to two-way ANOVA, considering a significance level of 5%.

Results:

The groups submitted to radiation presented lower shear strength values (4.48MPa) than those not irradiated (9.23MPa) (p< 0.001), and the tested composites were not statistically different (p= 0.078). Regarding the fracture mode, all the groups presented mostly adhesive fractures.

Conclusion:

It was concluded that ionizing radiation negatively affects the adhesion of ceramic brackets, regardless of the composite used for bonding.

Impact of Preoperative Risk Factors on Inpatient Stay and Facility Discharge After Free Flap Reconstruction

OBJECTIVE

To determine the preoperative risk factors most predictive of prolonged length of stay (LOS) or admission to a skilled nursing facility (SNF) or inpatient rehabilitation center (IPR) after free flap reconstruction of the head and neck.

STUDY DESIGN

Retrospective cohort study.

SETTING

Tertiary academic medical center.

METHODS

Retrospective review of 1008 patients who underwent tumor resection and free flap reconstruction of the head and neck at a tertiary referral center from 2002 to 2019.

RESULTS

Of 1008 patients (65.7% male; mean age of 61.4 years, SD 14.0 years), 161 (15.6%) were discharged to SNF/IPR, and the median LOS was 7 days. In multiple linear regression analysis, Charlson Comorbidity Index (CCI; P < .001), American Society of Anesthesiologists (ASA) classification (P = .021), female gender (P = .023), and inability to tolerate oral diet preoperatively (P = .006) were statistically significantly related to increased LOS, whereas age, body mass index (BMI), modified frailty index (MFI), a history of prior radiation or chemotherapy, and home oxygen use were not. Multiple logistic regression analysis demonstrated that CCI (odds ratio [OR] = 1.119, confidence interval [CI] 1.023-1.223), age (OR = 1.082, CI 1.056-1.108), and BMI <19.0 (OR = 2.141, CI 1.159-3.807) were the only variables statistically significantly related to posthospital placement in an SNF or IPR.

CONCLUSION

Common tools for assessing frailty and need for additional care may be inadequate in a head and neck reconstructive population. CCI appears to be the best of the aggregate metrics assessed, with significant relationships to both LOS and placement in SNF/IPR.

The Tumor Microenvironment in SCC: Mechanisms and Therapeutic Opportunities

Squamous cell carcinoma (SCC) is the second most common skin cancer worldwide and, despite the relatively easy visualization of the tumor in the clinic, a sizeable number of SCC patients are diagnosed at advanced stages with local invasion and distant metastatic lesions. In the last decade, immunotherapy has emerged as the fourth pillar in cancer therapy via the targeting of immune checkpoint molecules such as programmed cell-death protein-1 (PD-1), programmed cell death ligand-1 (PD-L1), and cytotoxic T-lymphocyte-associated protein 4 (CTLA-4). FDA-approved monoclonal antibodies directed against these immune targets have provide survival benefit in a growing list of cancer types. Currently, there are two immunotherapy drugs available for cutaneous SCC: cemiplimab and pembrolizumab; both monoclonal antibodies (mAb) that block PD-1 thereby promoting T-cell activation and/or function. However, the success rate of these checkpoint inhibitors currently remains around 50%, which means that half of the patients with advanced SCC experience no benefit from this treatment. This review will highlight the mechanisms by which the immune checkpoint molecules regulate the tumor microenvironment (TME), as well as the ongoing clinical trials that are employing single or combinatory therapeutic approaches for SCC immunotherapy. We also discuss the regulation of additional pathways that might promote superior therapeutic efficacy, and consequently provide increased survival for those patients that do not benefit from the current checkpoint inhibitor therapies.

Evaluation of patient specific care needs during treatment for head and neck cancer

BACKGROUND

Tumorous diseases of the head and neck region annually occur in more than 550.000 cases worldwide. Little is known about patient specific care needs and potential relationships between non-fulfillment of those following therapeutic and especially surgical treatment of head and neck cancer (HNC).

OBJECTIVES

This study aimed to evaluate potential correlations between patient specific care needs, regarding physiological rehabilitation, family/social support, economic needs, and their impact on health-related quality of life (HRQoL).

METHODS

A total of 1359 patients were included in this retrospective analysis. Data derived from the exploratory international multicenter rehabilitation study of the German-Austrian-Swiss Cooperative Group on Tumors of the Maxillofacial Region (DÖSAK), including 43 oral and maxillofacial departments in Germany, Austria, and Switzerland using the Bochum patient questionnaire on rehabilitation and a questionnaire on tumor and treatment related data.

RESULTS

Results showed a significant correlation of a patient's social bonds and depression, coping with depression, and anxiety. Patients' needs for speech therapy, physiotherapy or respiratory training were hardly ever met and patients had to compensate for financial losses during hospitalization for acute treatment.

CONCLUSION

In conclusion, this study describes social, physical, and socio-economic care needs. A multidisciplinary approach managing cancer and treatment related side effects is necessary, as well as enhanced awareness of care needs of practitioners during early recovery after surgery.

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.

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.

Testing the Timing: Time Factor in Radiation Treatment for Head and Neck Cancers

OPINION STATEMENT

Overall radiation treatment time has long been recognized as an important factor in head and neck tumor control. The concern of tumor growth in waiting time either before starting radiotherapy or during treatment is substantial given its negative impact on clinical outcome. There is an overwhelming evidence that increasing the time to initiate treatment increases the tumor burden and worsens the prognosis. This effect is more pronounced especially in patients with an early stage cancer disease. Delay in treatment initiation is contributed by both health care- and patient-related factors. Health care-related factors include advancement in diagnostic modalities and transfer of patient to academic health care centers accompanied by delayed referrals and long-awaited appointments. Patient-related factors include delayed reporting time and socioeconomic factors. An efficient transition of care along with access of cancer care modalities to community health care centers will not only improve the quality of care in secondary health care centers but also help decrease the patient burden in tertiary centers. A quick and well-structured multidisciplinary appointment program is fundamental in shortening the time required for patient referrals, thus increasing the optimal survival time for Head and Neck cancer patients with early initiation of treatment.

Oral squamous cell carcinoma: a clinicopathological study on 194 cases in northeastern Brazil. A cross-sectional retrospective study

BACKGROUND

Only a few studies have evaluated the clinicopathological features of oral squamous cell carcinoma (SCC) in Brazil, and most were conducted in the most industrialized region of the country, i.e. the southeastern region. The aim of this study was to evaluate the clinicopathological features of this malignant neoplasm in northeastern Brazil.

DESIGN AND SETTING

Retrospective study performed in an oral pathology laboratory in Recife, Brazil.

METHODS

All cases of oral SCC that occurred between 2000 and 2015 were studied. Clinical data were recorded and histological slides were reviewed. Statistical analysis was performed using the chi-square test (P ≤ 0.05).

RESULTS

A total of 194 cases were evaluated. The male-to-female ratio was 1.5:1. The mean age was 65.4 years, and only 6.6% of the cases occurred in patients younger than 41 years. Most tumors consisted of well-differentiated SCC (54.6%).

CONCLUSIONS

The findings of this study highlight the higher prevalence of oral SCC among women and the increasing number of cases among young patients. Thus there is no specific risk group for oral SCC, as in the past. This fact needs to be taken into consideration in clinical routine care, so that apparently innocuous malignant lesions do not go unnoticed in these individuals.

Glass Ionomer Cements can be used for Bonding Orthodontic Brackets After Cancer Radiation Treatment?

Patients undergoing radiotherapy treatment present more susceptibility to dental caries and the use of an orthodontic device increases this risk factor due to biofilm accumulation around the brackets. The objective of this study was to evaluate the shear bond strength to irradiated permanent teeth of orthodontic brackets bonded with conventional glass ionomer cement and resin-modified glass ionomer cement due to the fluoride release capacity of these materials. Ninety prepared human premolars were divided into 6 groups (n=15), according to the bonding material and use or not of radiation: CR: Transbond XT composite resin; RMGIC: Fuji Ortho LC conventional glass ionomer cement; GIC: Ketac Cem Easymix resin-modified glass ionomer cement. The groups were irradiated (I) or non-irradiated (NI) prior to bracket bonding. The specimens were subjected to a fractioned radiation dose of 2 Gy over 5 consecutive days for 6 weeks. After the radiotherapy, the brackets were bonded on the specimens with Transbond XT, Fuji Ortho LC and Ketac Cem Easymix. After 24 h, the specimens were subjected to shear bond strength test. The image of enamel surface (classified by Adhesive Remnant Index - ARI) was also evaluated and its frequency was checked among groups/subgroups. The shear bond strength variable was evaluated with ANOVA and Tukey's post-hoc test. GIC group showed the lowest adhesion values among the groups (p<0.05). There was no statistically significant difference among non-irradiated and irradiated groups (p>0.05). As for the ARI, the CR-I group showed the highest material retention on enamel surface among the irradiated groups. RMGIC group showed the highest values for shear bond strength and presented ARI acceptable for clinical practices.

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.

Health professionals and the early detection of head and neck cancers: a population-based study in a high incidence area

Background

In the context of early detection of head and neck cancers (HNC), the aim of this study was to describe how people sought medical consultation during the year prior to diagnosis and the impact on the stage of the cancer.

Methods

Patients over 20 years old with a diagnosis of HNC in 2010 were included from four French cancer registries. The medical data were matched with data regarding uptake of healthcare issued from French National Health Insurance General Regime.

Results

In 86.0 % of cases, patients had consulted a general practitioner (GP) and 21.1 % a dentist. Consulting a GP at least once during the year preceding diagnosis was unrelated to Charlson index, age, sex, département, quintile of deprivation of place of residence. Patients from the ‘quite privileged’, ‘quite underprivileged’ and ‘underprivileged’ quintiles consulted a dentist more frequently than those from the ‘very underprivileged’ quintile (p = 0.007).

The stage was less advanced for patients who had consulted a GP (OR = 0.42 [0.18–0.99]) - with a dose–response effect.

Conclusions

In view of the frequency of consultations, the existence of a significant association between consultations and a localised stage at diagnosis and the absence of a socio-economic association, early detection of HNC by GPs would seem to be the most appropriate way.

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.

Survival Impact of Increasing Time to Treatment Initiation for Patients With Head and Neck Cancer in the United States

PURPOSE

To estimate the overall survival (OS) impact from increasing time to treatment initiation (TTI) for patients with head and neck squamous cell carcinoma (HNSCC).

METHODS

Using the National Cancer Data Base (NCDB), we examined patients who received curative therapy for the following sites: oral tongue, oropharynx, larynx, and hypopharynx. TTI was the number of days from diagnosis to initiation of curative treatment. The effect of TTI on OS was determined by using Cox regression models (MVA). Recursive partitioning analysis (RPA) identified TTI thresholds via conditional inference trees to estimate the greatest differences in OS on the basis of randomly selected training and validation sets, and repeated this 1,000 times to ensure robustness of TTI thresholds.

RESULTS

A total of 51,655 patients were included. On MVA, TTI of 61 to 90 days versus less than 30 days (hazard ratio [HR], 1.13; 95% CI, 1.08 to 1.19) independently increased mortality risk. TTI of 67 days appeared as the optimal threshold on the training RPA, statistical significance was confirmed in the validation set (P < .001), and the 67-day TTI was the optimal threshold in 54% of repeated simulations. Overall, 96% of simulations validated two optimal TTI thresholds, with ranges of 46 to 52 days and 62 to 67 days. The median OS for TTI of 46 to 52 days or fewer versus 53 to 67 days versus greater than 67 days was 71.9 months (95% CI, 70.3 to 73.5 months) versus 61 months (95% CI, 57 to 66.1 months) versus 46.6 months (95% CI, 42.8 to 50.7 months), respectively (P < .001). In the most recent year with available data (2011), 25% of patients had TTI of greater than 46 days.

CONCLUSION

TTI independently affects survival. One in four patients experienced treatment delay. TTI of greater than 46 to 52 days introduced an increased risk of death that was most consistently detrimental beyond 60 days. Prolonged TTI is currently affecting survival.

[Delayed referrals of oral cancer patients: the perception of dental surgeons]

The scope of this study was to verify the possible reasons to justify the delay in the referral of oral cancer patients to specialized health care sectors from the standpoint of the dental surgeons involved in Primary Health Care (PHC) in Porto Alegre, state of Rio Grande do Sul. This target public of this study was dental surgeons working in five different labor environments in PHC in Porto Alegre. Criteria for inclusion was dental surgeons graduated in and working in PHC. The data collection instrument was the focus group technique and application of a structured questionnaire. After data collection, interpretative analysis was conducted with classification of the information under four main headings: professional, team, community and services network. The results suggest that there are several factors associated with delayed in referral of patients with oral cancer to specialized health care sectors. These include omission of early diagnosis, lack of multidisciplinary work and insufficient attention to the need for joint community responsibility with patients for their own health status. It is also due to deficiencies in the health service network, specifically regarding the quality of communication between professionals at different levels of the health services.

Physical and adhesive properties of dental enamel after radiotherapy and bonding of metal and ceramic brackets

INTRODUCTION

The increasing success rates for cancer patients treated with radiotherapy and the frequent occurrence of tooth loss during treatment have led to an increased demand for orthodontic treatment after radiotherapy. The aim of this study was to evaluate tooth enamel of irradiated teeth after the bonding and debonding of metal and ceramic brackets.

METHODS

Ten permanent molars were cut into enamel fragments measuring 1 mm(2) and divided into an irradiated group (total dose of 60 Gy) and a nonirradiated group. The fragments were subjected to microshear testing to evaluate whether radiotherapy altered the strength of the enamel. Furthermore, 90 prepared premolars were divided into 6 groups and subgroups (n = 15): group 1, nonirradiated and nonaged; group 2, nonirradiated and aged (thermal cycled); group 3, irradiated and aged; each group was divided into 2 subgroups: metallic and ceramic brackets. After thermal cycling and radiotherapy, the brackets were bonded onto the specimens with Transbond XT (3M Unitek, Monrovia, Calif). After 24 hours, the specimens were subjected to the shear tests. Images of the enamel surfaces were classified using the adhesive remnant index. The composite resin-enamel interface was also evaluated.

RESULTS

Enamel fragments subjected to radiation had lower strength than did the nonirradiated samples (P <0.05). The groups and subgroups submitted to radiation and bonded ceramic brackets had the lowest strength values. Groups 1 and 2 with metallic brackets had less adhesive on the surface, whereas groups 1 and 2 with ceramic brackets and group 3 with both metallic and ceramic brackets had more adhesive on the surfaces. On the images of the composite resin-enamel interface, resin tags were more extensive on irradiated tooth enamel.

CONCLUSIONS

Radiation decreased tooth enamel strength, and the specimens treated with radiotherapy had higher frequencies of adhesive failure between the bracket and the composite resin as well as more extensive tags.

Screening and referral of oral mucosal pathology: a check-up of Australian dentists

BACKGROUND

Oral squamous cell carcinomas and potentially malignant oral disorders can be detected early by visually inspecting the oral soft tissues. This study aimed to determine Australian dentists' opinions and practices regarding oral mucosal screening, referral and oral cancer prevention.

METHODS

Nine hundred and ninety-nine randomly selected general dentists were mailed a questionnaire. The questionnaire queried practitioners' opinions and perceptions of oral mucosal screening, their referral practices and their beliefs regarding detection and prevention of oral cancer.

RESULTS

A total of n=640 individuals responded, yielding a response rate of 70.2%. Most Australian dentists reported to routinely perform oral mucosal screening. Lack of training, confidence, time and financial incentives were seen as barriers to performing mucosal screening to at least some degree by participants in this study. Most dentists manage referrals for oral mucosal pathology appropriately; however, only about half believe in following up with referred patients. Only half of dentists surveyed believed that they could influence a patient to quit smoking.

CONCLUSIONS

Australian dentists place importance on oral mucosal screening. Some changes to dental education and training could be made to further improve confidence and ability of dentists in detecting and referring oral mucosal pathology.

Over-reassurance and undersupport after a 'false alarm': a systematic review of the impact on subsequent cancer symptom attribution and help seeking

OBJECTIVES

This literature review examined research into the impact of a previous 'all-clear' or non-cancer diagnosis following symptomatic presentation ('false alarm') on symptom attribution and delays in help seeking for subsequent possible cancer symptoms.

DESIGN AND SETTING

The comprehensive literature review included original research based on quantitative, qualitative and mixed data collection methods. We used a combination of search strategies, including in-depth searches of electronic databases (PubMed, EMBASE, PsychInfo), searching key authors and articles listed as 'related' in PubMed, and reference lists. We performed a narrative synthesis of key themes shared across studies.

PARTICIPANTS

The review included studies published after 1990 and before February 2014 reporting information on adult patients having experienced a false alarm following symptomatic presentation. We excluded false alarms in the context of screening.

PRIMARY AND SECONDARY OUTCOME MEASURES

We evaluated the effect of a 'false alarm' on symptom attribution and help seeking for new or recurrent possible cancer symptoms.

RESULTS

Overall, 1442 papers were screened and 121 retrieved for full-text evaluation. Among them, 19 reported on false alarms and subsequent symptom attribution or help seeking. They used qualitative (n=14), quantitative (n=3) and mixed methods (n=2). Breast (n=7), gynaecological (n=3), colorectal (n=2), testicular (n=2), and head and neck cancers (n=2) were the most studied. Two broad themes emerged underlying delays in help seeking: (1) over-reassurance from the previous 'all-clear' diagnosis leading to subsequent symptoms being interpreted as benign, and (2) unsupportive healthcare experiences in which symptoms were dismissed, leaving patients concerned about appearing hypochondriacal or uncertain about the appropriate next actions. The evidence suggested that the effect of a false alarm can persist for months and even years.

CONCLUSIONS

In conclusion, over-reassurance and undersupport of patients after a false alarm can undermine help seeking in the case of new or recurrent potential cancer symptoms, highlighting the need for appropriate patient information when investigations rule out cancer.

Late stage diagnosis of oral cancer: components and possible solutions

Stage of disease at the diagnosis of oral cancer is thought to be a significant factor in prognosis and outcome (International Agency for Research on Cancer/World Health Organization, 2014). Unfortunately, we continue to diagnose almost 2/3 of these cancers at advanced stages of disease despite the ongoing research for devices/methods to aid the clinicians in detection and accurate oral mucosal lesion diagnosis. This paper explores both the nature of oral cancer and the adjuncts available for detection, and presents the current issues in diagnostic delays of oral cancer detection.

Oral mucosal screening and referral attitudes of Australian oral health therapists and dental hygienists in Queensland

OBJECTIVES

The aim of this study was to describe oral mucosal screening and referral attitudes of Australian oral health therapists (OHTs) and dental hygienists (DHs).

METHODS

Questionnaires were distributed to participants who attended dental hygiene courses run in both regional and metropolitan Queensland.

RESULTS

One hundred and two participants comprised 58 OHTs and 44 DHs, with a mean of 8.9 years since graduation. Thirty-four participants worked in regional locations, while 68 were from metropolitan areas. 97% of participants agreed that mucosal screening should be performed for all new and recall patients, while a minority (5%) agreed that patients will detect an oral mucosal change themselves. The majority (77%) agreed that oral cancer would be encountered in their practising career. Most participants (81%) felt comfortable discussing the presence of a suspicious lesion with patients and 88% agreed that it was their role to screen. In terms of barriers to oral cancer screening, lack of training was seen as the most prevalent barrier (56%) followed by lack of confidence (51%). Lack of time was seen as the third most prevalent barrier (40%), and lack of financial incentives was the least prevalent barrier (16%).

CONCLUSIONS

Oral health therapists and DHs understand the importance of oral mucosal screening and are likely to be alert to oral mucosal changes. While lack of time and financial incentives was perceived to be impediments to mucosal screening, lack of confidence and training was the most prevalent barriers. This issue should be addressed through implementation of effective continuing education courses targeting oral cancer screening and referral practices.

The importance of contextualization. Anthropological reflections on descriptive analysis, its limitations and implications

This paper regards a concern for the quality of analyses made on the basis of qualitative interviews in some parts of qualitative health research. Starting with discussions departing in discussions on studies exploring 'patient delay' in healthcare seeking, it is argued that an implicit and simplified notion of causality impedes reflexivity on social context, on the nature of verbal statements and on the situatedness of the interview encounter. Further, the authors suggest that in order to improve the quality of descriptive analyses, it is pertinent to discuss the relationship between notions of causality and the need for contextualization in particular. This argument targets several disciplines taking a qualitative approach, including medical anthropology. In particular, researchers working in interdisciplinary fields face the demands of producing knowledge ready to implement, and such demands challenge basic notions of causality and explanatory power. In order to meet these, the authors suggest an analytic focus on process causality linked to contextualization.

Diagnostic delay in oral squamous cell carcinoma: the role of cognitive and psychological variables

This retrospective study investigated, in two cohorts of subjects living in Southern Italy and awaiting treatment for oral squamous cell carcinoma (OSCC), the variables related to diagnostic delay ascribable to the patient, with particular reference to the cognitive and psychological ones. A total of 156 patients with OSCC (mean age: 62 years, M/F: 2.39∶1) were recruited at the Universities of Palermo and Naples. Risk factors related to patient delay included: sociodemographic, health-related, cognitive and psychological variables. The analysis was conducted by considering two different delay ranges: dichotomous (≤1 month vs. >1 month) and polytomous (<1 month, 1-3 months, >3 months) delay. Data were investigated by univariate and multivariate analyses and a P value ≤0.05 was considered statistically significant. For both delay measurements, the most relevant variables were: 'Personal experience of cancer' (dichotomous delay: P=0.05, odds ratio (OR)=0.33, 95% confidence interval (CI)=0.11-0.99; polytomous delay: P=0.006, Chi-square=10.224) and 'Unawareness' (dichotomous delay: P<0.01, OR=4.96, 95% CI=2.16-11.37; polytomous delay: P=0.087, Chi-square=4.77). Also 'Denial' (P<0.01, OR=6.84, 95% CI=2.31-20.24) and 'Knowledge of cancer' (P=0.079, Chi-square=8.359) were found to be statistically significant both for dichotomous and for polytomous categorization of delay, respectively. The findings of this study indicated that, in the investigated cohorts, the knowledge about cancer issues is strongly linked to the patient delay. Educational interventions on the Mediterranean population are necessary in order to increase the patient awareness and to emphasize his/her key role in early diagnosis of OSCC.

Journey of patients with cancer: a systematic evaluation at tertiary care center in India

In cancer patients early institution of therapy placed a very important role and delay in the diagnosis and treatment can cause catastrophe. Affirm step to cut shot this delay requires detailed information about each step of patient referral journey and for fulfillment of above aim, we interviewed 101 patients, to calculate the elapsed time at each step. Result revealed that onset of symptoms to median time of presentation to general practitioner is 20 (9 - 28) days, time consumed in state based hospital is 100 (15- 167) days while in Delhi based hospital is 56 (18 - 100) days. Higher cure rate (38.2%) in patients presented within 3 months of development of cancer symptoms than those presented late. Study concluded that primary physician and all the referral hospital attributed important role in early diagnosis and treatment of cancer.

Analysis of ECOG performance status in head and neck squamous cell carcinoma patients: association with sociodemographical and clinical factors, and overall survival

PURPOSE

In the present study, we analyzed sociodemographical and clinical factors, and the Eastern Cooperative Oncology Group performance status (ECOG-PS) scale in head and neck squamous cell carcinoma (HNSCC) patients. We evaluated the impact of a range of variables on overall survival.

METHODS

We investigated a sample of HNSCC patients (n = 671), using sociodemographical and clinical information, and survival data collected from a review of epidemiological, clinical, and treatment reports. Statistical associations were analyzed by bivariate and multivariate statistical tests. Statistical significance was set at p < 0.05.

RESULTS

Of patients 85.4% recorded good ECOG-PS scores. Poor ECOG-PS scores were associated with the covariates indicative of dysphagia [odd ratios (OR) = 2.660, CI 95% = 1.661–4.260, p = 0.000] and large-size malignant disease (T3–T4; OR = 5.337, CI 95% = 2.251–12.652, p = 0.000). Overall survival analysis revealed that ECOG-PS scores (OR = 1.879, CI 95% = 1.162–3.038, p = 0.010), tumor size (OR = 1.665, CI 95% = 1.035–2.680, p = 0.036), and the presence of cervical metastasis (OR = 3.145, CI 95% = 2.008–4.926, p = 0.000) were independent predictors.

CONCLUSION

Evaluation of physical consumption in head and neck cancer patients at diagnosis may indicate a more aggressive type of malignant disease. Thus, the ECOG-PS scale may help to identify HNSCC patients in need of rapid referral, who may benefit from specific therapeutic and rehabilitative interventions.

Palliative and end of life care issues of carcinoma thyroid patient

Malignancies of the thyroid gland has steadily increased over the last few decades, out of which mostly are differentiated carcinomas of the papillary or of follicular type, have a good prognosis and highest cure rate if treatment commences early. Here, we report a case of an 18-years-old boy with a huge multinodular goiter, which compromised the airway and lung metastasis, presented at advance stage of disease in tertiary care center. Factors prevent early diagnosis and treatment, distressing symptoms patient can develop, palliation of those symptoms, and effort to be made to prevent the delay are highlighted.

Referral of elderly cancer patients to specialists: action proposals for general practitioners

BACKGROUND

Many studies have identified advanced age as a barrier to accessing specialized oncological care.

OBJECTIVES

To identify elements from the literature influencing general practitioners (GPs) in their decisions to refer elderly patients with cancer to oncology teams, and propose focused actions to improve referral processes.

METHODS

Eligible articles published up to July 2010 identifying factors associated with referral decisions for elderly cancer patients were selected. A quality assessment of each article was performed. All factors identified were considered for possible interventions classified by the Effective Practice and Organisation of Care (EPOC) taxonomy and development of recommendations for referral of elderly patients.

RESULTS

Thirty eligible articles were found with only 18 articles specifically exploring factors influencing physicians in the referral of their patients with cancer. Twelve focused on delay to treatment and only two uniquely on elderly patients. Patient age was the main factor associated with referral decisions, but this factor can influence GP's differently depending on the type of cancer. The small size of these studies, heterogeneity of study populations, and diversity of outcome measures used meant that compilation of guidelines based on high-quality evidence was not possible. However, organizational factors hindering decisions to refer are identified and highlighted as crucial for inclusion in intervention programs, specifically to reach GPs in smaller locations or with less experience in collaborating with specialists. For patient-related factors, professional and organizational interventions are necessary, aimed at both GPs and patients to update knowledge of the non-linear relationship between chronological age and a patient's ability to tolerate treatment.

CONCLUSIONS

First and foremost, this article highlights the scarcity of literature specific to elderly patients with cancer. It also identifies the public health need for better knowledge of the factors for referral of elderly patients. Focussed action proposals are presented to improve knowledge and consequently, optimize the referral process.

Oral cancer knowledge: a survey administered to patients in dental departments at large Italian hospitals

We assessed the oral cancer (OC) knowledge, including risk factors and clinical symptoms, among patients attending dental departments within Italian university hospitals. Two thousand and two hundred questionnaires were sent to four hospitals in order to assess patients' knowledge regarding clinical and epidemiological aspects of OC; OC knowledge was evaluated overall and stratified by oral cancer family history. Participants frequently identified cigarette smoking (87.8%) and heavy alcohol consumption (58.6%) as a risk factor for oral cancer, knew the clinical signs of OC (65-79% depending on the specific symptom) and reported that early detection was related to better prognosis of oral cancer (94%). Individuals with a positive family history for oral cancer were significantly more likely to identify risk factors for oral cancer correctly yet family history of OC did not affect smoking status. Less than 15% of patients reported having received OC counseling by a dentist or physician.

Factors associated with late presentation of cancer: a limited literature review

According to the World Health Organization (WHO 2006), cancer is one of the leading causes of death worldwide. Deaths from cancer are projected to continue rising, with an estimated 9 million people dying from cancer in 2015 and 11.4 million dying in 2030 (WHO 2006). Delayed presentation or late diagnosis of cancer is associated with low survival. The aim of this review is to identify factors associated with delayed presentation of cancer that were reported by previous studies. Published studies which identified the most common factors attributed to the late presentation of cancer were reviewed. Publications were identified using MEDLINE (Medical Literature Analysis and Retrieval System Online), the Cochrane Library, CINAHL (Cumulative Index to Nursing and Allied Health Literature) and EMBASE (Excerpta Medica Database) databases. A Critical Appraisal Skills Programme (CASP) was used to assess the methodological quality of the studies. A total of 24 studies met the inclusion criteria. A data extraction sheet was used to systematically record relevant factors. Twenty-four studies met the inclusion criteria which identified factors associated with patients’ delay including patients’ knowledge, stress and fear, and nature of the disease. Other factors were attributed to health providers such as general practitioner (GP) experience, referral delay, and a younger age group being considered as low risk, so symptoms were missed.

Psychometric properties of Scheier and Carver's Life Orientation Test in a sample of Australian prisoners

The psychometric properties of Scheier and Carver's 1985 Life Orientation Test (LOT), which is a measure of optimism, were examined as part of a study of education, training, work experience, and expectations of sentenced adult prisoners in Western Australia. All prisoners at five metropolitan public prisons were invited to participate and 453 accepted. This represented a response rate overall of about 41%, with response rates at each of the individual prisons ranging from 13% to 90%. The average age of the prisoner sample was 34.4 yr. (SD = 10.2 yr.). The proportion of men in the sample was 79.7%. Mean sentence length was 66.9 mo. (58.5 for women and 69.2 for men), and the number of months of sentence remaining averaged 44.4 mo. (41.0 for women and 45.3 for men). Means and standard deviations of the LOT scores for prisoners were similar to those of other groups, and demographic differences between prisoners were not statistically significantly related to scores. The internal reliability of the LOT scores was acceptable. Confirmatory factor analyses indicated that the two-factor item-keying model fitted the prisoner data better than a one-factor model. However, the two factors did not simply reflect underlying optimism and pessimism constructs but were substantially affected by item keying.

Head and neck cancer in primary care: presenting symptoms and the effect of delayed diagnosis of cancer cases

BACKGROUND

Little is known about the diagnosis of head and neck carcinoma in primary care. We sought to estimate the general prevalence of symptoms reported by patients with head and neck carcinomas and to determine the association between detection patterns of head and neck cancer cases in primary care and survival.

METHODS

In a cross-sectional survey, we used a questionnaire to estimate the general prevalence of symptoms associated with head and neck cancer from a sample of 5646 primary care visits in 25 randomly selected health centres over 4 weeks throughout Finland. A population-based retrospective cohort study involved the 221 patients resident in one primary health care district (population about 700,000) in whom head and neck carcinoma was diagnosed between Jan. 1, 1986, and Dec. 31, 1996. Data on the initial primary care visit, clinical characteristics and survival were obtained from patient charts.

RESULTS

Of 5646 visits to a primary care practitioner, 11% (617) were made because of the same symptoms as those initially reported by patients later found to have head and neck cancer. According to the cohort data, the detection rate of these carcinomas in primary care was 1 per 63,000 visits. At the initial visit of 221 patients later found to have cancer, 56% (123) received referrals, 24% (53) follow-up appointments and 20% (45) neither ("overlooked"). At 3 years, the risk of death was significantly higher among patients whose disease was overlooked (adjusted hazard ratio [HR] 1.89, 95% confidence interval [CI] 1.03-3.45). The excess risk associated with being overlooked, however, was confined to subjects with tongue or glottic tumours (HR 4.25, 95% CI 1.59- 11.4) (number needed to harm 3.0, 95% CI 1.9-6.7).

INTERPRETATION

Despite the rarity of patients with head and neck carcinoma in primary care, patients with symptoms of these diseases and especially with symptoms of tongue and glottic carcinomas should be initially referred for further care or followed up.