Experience of, awareness of and help-seeking for potential cancer symptoms in smokers and non-smokers: A cross-sectional study

Analysis of Diagnostic Delay and its Impact on Lung Cancer Survival: Results From the Spanish Thoracic Tumor Registry

BACKGROUND

Early detection is crucial to improve lung cancer survival rates. Delays in diagnosis might negatively impact the prognosis of the disease. This study aims to analyze the diagnostic delay in lung cancer patients and describe if there is an association between delay and survival.

METHODS

The data source used was the Thoracic Tumor Registry of the Spanish Lung Cancer Group. This analysis was restricted to lung cancer cases with information on the first date of consultation by symptoms and date of diagnosis. The delay was calculated as the number of days between the two dates. A descriptive analysis was performed, and ordinal logistic regressions were fitted with delay as the dependent variable. Kaplan-Meier survival analysis and Cox regression were performed.

RESULTS

22,755 lung cancer cases were included. Never smokers were 1.16 (95%CI: 1.06-1.27) times more likely to register longer delay than smokers. Stage 0-I-II cases had a 3.09 (95%CI: 2.88-3.32) higher risk of longer delay compared to III-IV stages. Overall, 5-year survival rate after diagnosis was 23.64% (95%CI: 22.88-24.41). In those categorized as having the shortest delay 5-year survival was 17.67% (95%CI: 16.31-19.07) and in the extreme delay it was 32.98% (95%CI: 31.28-34.69) (p<0.001). Adjusted mortality risk was higher in those with the shortest delay (HR 1.36, CI95%: 1.30-1.43) in comparison with the extreme delay.

CONCLUSIONS

Diagnostic delay is short among Spanish lung cancer patients, indicating a relatively quick diagnostic process. Extreme delays appear to be associated with higher survival rates, possibly attributed to slow-growing tumors, earlier stage at diagnosis or basically the natural history of this disease.

Investigating the role of symptom valorisation in tuberculosis patient delay in urban areas in Portugal

BACKGROUND

Diagnosis delay contributes to increased tuberculosis (TB) transmission and morbimortality. TB incidence has been decreasing in Portugal, but median patient delay (PD) has risen. Symptom valorisation may determine PD by influencing help-seeking behaviour. We aimed to analyse the association between symptom valorisation and PD, while characterising individuals who disregarded their symptoms.

METHODS

A cross-sectional study was conducted among TB patients in Lisbon and Oporto in 2019 - 2021. Subjects who delayed seeking care because they did not value their symptoms or thought these would go away on their own were considered to have disregarded their symptoms. PD was categorised using a 21-day cut-off, and a 30-day cut-off for sensitivity analysis. We estimated the effect of symptom valorisation on PD through a directed acyclic graph. Then, a multivariable regression analysis characterised patients that disregarded their symptoms, adjusting for relevant variables. We fitted Poisson regression models to estimate crude and adjusted prevalence ratios (PR).

RESULTS

The study included 75 patients. Median PD was 25 days (IQR 11.5-63.5), and 56.0% of participants had PD exceeding 21 days. Symptom disregard was reported by 38.7% of patients. Patients who did not value their symptoms had higher prevalence of PD exceeding 21 days compared to those who valued their symptoms [PR 1.59 (95% CI 1.05-2.42)]. The sensitivity analysis showed consistent point estimates but wider confidence intervals [PR 1.39 (95% CI 0.77-2.55)]. Being a smoker was a risk factor for symptom disregard [PR 2.35 (95% CI 1.14-4.82)], while living in Oporto [PR 0.35 (95% CI 0.16-0.75)] and having higher household incomes [PR 0.39 (95% CI 0.17-0.94)] were protective factors.

CONCLUSIONS

These findings emphasise the importance of symptom valorisation in timely TB diagnosis. Patients who did not value their symptoms had longer PD, indicating a need for interventions to improve symptom recognition. Our findings also corroborate the importance of the socioeconomic determinants of health, highlighting tobacco as a risk factor both for TB and for PD.

Ever Smoking is Not Associated with Performed Spirometry while Occupational Exposure and Respiratory Symptoms are

Objective

Despite recommendations, assessment using spirometry or peak expiratory flow is insufficient in the clinical evaluation of suspected obstructive pulmonary disease. The aim was to investigate factors associated with performing spirometry or peak flow expiratory flow assessment.

Methods

Randomly selected subjects from the general population aged 50-65 completed a respiratory questionnaire with items about the history of previously performed spirometry or peak expiratory flow. The association between ever having had spirometry or peak expiratory flow performed was analyzed for smoking, age, sex, occupational exposures, dyspnea, wheeze, self-reported physician diagnosed asthma and COPD using multivariable logistic regression models. The results are presented as odds ratios (OR) with 95% confidence intervals (95% CIs).

Results

Of the 1105 participants, 43.4% (n=479) had a history of previously performed spirometry or peak expiratory flow. Occupational exposure (OR 1.72, [95% CI] 1.30-2.27), wheeze (OR 2.29, 1.41-3.70), and dyspnea (OR 1.70, 1.11-2.60) were associated with previously performed spirometry. Compared to men, women had spirometry or peak expiratory flow performed less often (OR 0.67, 0.51-0.86). Neither current smoking (OR 0.83, 0.57-1.20) or former smoking (OR 1.27, 0.96-1.67) were associated with performed spirometry or peak expiratory flow.

Conclusion

We found no relation between smoking status and a history of previously performed spirometry or peak expiratory flow in a population-based sample of middle-aged people. This is surprising regarding the strong guidelines which highlight the importance for spirometry surveillance on current smokers due to their increased risk of lung disease. Male sex, respiratory symptoms and occupational exposures to air pollution were associated with previously performed spirometry or peak expiratory flow. The association with occupational exposure may be an effect of pre-employment screening and workplace surveillance, and the findings indicate that females do not receive the same attention regarding spirometry or peak expiratory flow.

What are the similarities and differences in lung cancer symptom appraisal and help-seeking according to smoking status? A qualitative study with lung cancer patients

OBJECTIVE

Lung cancer in never-smokers represents a growing proportion of patients. The relationship between smoking status, symptom appraisal and help-seeking behaviour is complex. Little is known about cancer symptom-related health behaviours according to smoking status. The aim of the study was to explore lung cancer patients' experiences of a lung cancer diagnosis, identifying differences by smoking history.

METHOD

This was a qualitative study involving telephone interviews with 40 lung cancer patients (20 never smokers, 11 former smokers and 9 current smokers). We used framework analysis to analyse the data using the Common Sense Model of Illness Self-Regulation as a theoretical framework, developed after initial analysis.

RESULTS

All patients were likely to delay seeking help for symptoms in primary care regardless of smoking history, but for different reasons. Smoking history was instrumental to how individuals perceived and responded to early symptoms of lung cancer. Differences in interpretation and coping responses to new symptoms seemed to be caused by the higher presence of comorbidities due to smoking, and perceptions of the current state of health. Individuals with a smoking history reported acting with urgency in seeking help and follow up, whereas patients who experienced low levels of concern were more easily reassured by clinicians, resulting in delays.

CONCLUSIONS

Never and former smokers perceive, interpret, and respond to symptoms of lung cancer differently to smokers. However, few people attribute their lung symptoms to cancer initially, even with a smoking history. Interventions that drive increased urgency and vigilance in never smokers may be effective.

A population-based study on social inequality and barriers to healthcare-seeking with lung cancer symptoms

Healthcare-seeking with lung cancer symptoms is a prerequisite for improving timely diagnosis of lung cancer. In this study we aimed to explore barriers towards contacting the general practitioner (GP) with lung cancer symptoms, and to analyse the impact of social inequality. The study is based on a nationwide survey with 69,060 individuals aged ≥40 years, randomly selected from the Danish population. The survey included information on lung cancer symptoms, GP contacts, barriers to healthcare-seeking and smoking status. Information about socioeconomics was obtained by linkage to Danish Registers. Descriptive statistics and multivariate logistic regression model were used to analyse the data. “Being too busy” and “Being worried about wasting the doctor’s time” were the most frequent barriers to healthcare-seeking with lung cancer symptoms. Individuals out of workforce and individuals who smoked more often reported “Being worried about what the doctor might find” and “Being too embarrassed” about the symptoms. The social inequality in barriers to healthcare-seeking with lung cancer symptoms is noticeable, which emphasises the necessity of focus on vulnerable groups at risk of postponing relevant healthcare-seeking.

Lung cancer symptom appraisal, help-seeking and diagnosis - rapid systematic review of differences between patients with and without a smoking history

BACKGROUND

Lung cancer is the leading cause of cancer death in the world. A significant minority of lung cancer patients have never smoked (14% in the UK, and ranging from 10% to 25% worldwide). Current evidence suggests that never-smokers encounter delays during the diagnostic pathway, yet it is unclear how their experiences and reasons for delayed diagnoses differ from those of current and former smokers. This rapid review assessed literature about patient experiences in relation to symptom awareness and appraisal, help-seeking, and the lung cancer diagnostic pathway, comparing patients with and without a smoking history.

METHODS

MEDLINE, PsychINFO and Google Scholar were searched for studies (2010-2020) that investigated experiences of the pathway to diagnosis for patients with and without a smoking history. Findings are presented using a narrative synthesis.

RESULTS

Analysis of seven quantitative and three qualitative studies revealed that some delays during symptom appraisal and diagnosis are unique to never-smokers. Due to the strong link between smoking and lung cancer, and low awareness of non-smoking related lung cancer risk factors and symptoms, never-smokers do not perceive themselves to be at risk. Never-smokers are also likely to evaluate their experiences in comparison with other non-smoking related cancers, where prognosis is likely better, potentially leading to lower satisfaction with healthcare.

CONCLUSION

Never-smokers appear to have different experiences in relation to symptom appraisal and diagnosis. However, evidence in relation to help-seeking, and what is driving diagnostic delays for never-smoker patients specifically is lacking.

An evaluation of a national mass media campaign to raise public awareness of possible lung cancer symptoms in England in 2016 and 2017

BACKGROUND

A two-phase 'respiratory symptoms' mass media campaign was conducted in 2016 and 2017 in England raising awareness of cough and worsening shortness of breath as symptoms warranting a general practitioner (GP) visit.

METHOD

A prospectively planned pre-post evaluation was done using routinely collected data on 15 metrics, including GP attendance, GP referral, emergency presentations, cancers diagnosed (five metrics), cancer stage, investigations (two metrics), outpatient attendances, inpatient admissions, major lung resections and 1-year survival. The primary analysis compared 2015 with 2017. Trends in metrics over the whole period were also considered. The effects of the campaign on awareness of lung cancer symptoms were evaluated using bespoke surveys.

RESULTS

There were small favourable statistically significant and clinically important changes over 2 years in 11 of the 15 metrics measured, including a 2.11% (95% confidence interval 1.02-3.20, p < 0.001) improvement in the percentage of lung cancers diagnosed at an early stage. However, these changes were not accompanied by increases in GP attendances. Furthermore, the time trends showed a gradual change in the metrics rather than steep changes occurring during or after the campaigns.

CONCLUSION

There were small positive changes in most metrics relating to lung cancer diagnosis after this campaign. However, the pattern over time challenges whether the improvements are wholly attributable to the campaign. Given the importance of education on cancer in its own right, raising awareness of symptoms should remain important. However further research is needed to maximise the effect on health outcomes.

Evaluating the delay prior to primary care presentation in patients with lung cancer: a cohort study

Background

Little is known about 'within-patient delay', which is the time from first symptom of lung cancer to contacting primary care.

Aim

Primary outcomes were length of within-patient delay and the proportion of total delay it represents. Secondary outcomes were factors causing delay and survival.

Design & setting

A cohort study of newly diagnosed patients with lung cancer at two hospitals in Norfolk.

Method

Patients completed questionnaires regarding onset of symptoms, whether they had delayed, and their reasons. GPs completed correlating questionnaires. Pathway times and other data were extracted from cancer registry and hospital records, and outcomes obtained prospectively. Factors causing delay were compared using ratios of geometric means.

Results

In 379 patients, mean within-patient delay and pre-secondary care delay were 188.6 days and 241 days (61.4% and 78.5% of total delay, respectively). It was found that 38.8% of patients felt they had delayed. Patient-related causes of delay were denial (ratio of means [ROM] = 4.36; P = 0.002, 95% confidence interval [CI] = 1.71 to 11.1); anxiety (ROM = 3.36; P = 0.026; 95% CI = 1.16 to 9.76); non-recognition of symptoms (ROM = 2.80; P = 0.004; 95% CI = 1.41 to 5.59); and smoking (ROM = 1.76; P = 0.021; 95% CI = 1.09 to 2.86), respectively. These symptoms were associated with delay: finger swelling or discomfort (ROM = 2.72; P = 0.009, 95% CI = 1.29 to 5.74); cough (ROM = 2.53; P<0.001; 95% CI = 1.52 to 4.19); weight loss (ROM = 2.41; P<0.001; 95% CI = 1.49 to 3.88); weakness (ROM = 2.35; P = 0.001; 95% CI = 1.45 to 3.83); dyspnoea (ROM = 2.30; P = 0.001; 95% CI = 1.40 to 3.80); voice change (ROM = 1.90; P = 0.010; 95% CI = 1.17 to 3.10); and sputum (ROM = 1.66; P = 0.039; 95% CI = 1.03 to 2.67), respectively, also having more than five symptoms (compared with 1–3) (ROM = 3.69; P<0.001; 95% CI = 2.05 to 6.64). No overall relation between within-patient delay and survival was seen.

Conclusion

Using smoking registers, awareness literature, and self-care manuals, primary care staff could liaise with people who have ever smoked regarding their symptoms to ensure early referral to secondary care.

Sensations, symptoms, and then what? Early bodily experiences prior to diagnosis of lung cancer

Lung cancer (LC) generally lacks unique core symptoms or signs. However, there are a multitude of bodily sensations that are often non-specific, not easily understood, and many times initially not recognized as indicative of LC by the affected person, which often leads to late diagnosis. In this international qualitative study, we inductively analyzed retrospective accounts of 61 people diagnosed with LC in Denmark, England and Sweden. Using the bodily sensations they most commonly spoke about (tiredness, breathlessness, pain, and cough), we constructed four sensation-based cases to understand the pre-diagnostic processes of reasoning and practice triggered by these key indicators of LC. We thereafter critically applied Hay's model of sensations to symptoms transformation, examining its central concepts of duration, disability and vulnerability, to support understanding of these processes. We found that while duration and disability are clearly relevant, vulnerability is more implicitly expressed in relation to perceived threat. Tiredness, even when of long duration and causing disability, was often related to normal aging, rather than a health threat. Regardless of duration, breathlessness was disturbing and threatening enough to lead to care-seeking. Pain varied by location, duration and degree of disability, and thus also varied in degree of threat perceived. Preconceived, but unmet expectations of what LC-related cough and pain would entail could cause delays by misleading participants; if cough lasted long enough, it could trigger health care contact. Duration, disability, and sense of threat, rather than vulnerability, were found to be relevant concepts for understanding the trajectory to diagnosis for LC among these participants. The process by which an individual, their family and health care providers legitimize sensations, allowing them to be seen as potential symptoms of disease, is also an essential, but varying part of the diagnostic processes described here.

The promises and challenges of early non-small cell lung cancer detection: patient perceptions, low-dose CT screening, bronchoscopy and biomarkers

Lung cancer survival statistics are sobering with survival ranking among the poorest of all cancers despite the addition of targeted therapies and immunotherapies. However, improvements in tools for early detection hold promise. The Nederlands–Leuvens Longkanker Screenings Onderzoek (NELSON) trial recently corroborated the findings from the previous National Lung Screening Trial low‐dose Computerised Tomography (NLST) screening trial in reducing lung cancer mortality. Biomarker research and development is increasing at pace as the molecular life histories of lung cancers become further unravelled. Low‐dose CT screening (LDCT) is effective but targets only those at the highest risk and is burdensome on healthcare. An optimally designed CT screening programme at best will only detect a low proportion of overall lung cancers as only those at very high‐risk meet screening criteria. Biomarkers that help risk stratify suitable patients for LDCT screening, and those that assist in determining which LDCT detected nodules are likely to represent malignant disease are needed. Some biomarkers have been proposed as standalone lung cancer diagnosis tools. Bronchoscopy technology is improving, with better capacity to identify and obtain samples from early lung cancers. Clinicians need to be aware of each early lung cancer detection method’s inherent limitations. We anticipate that the future of early lung cancer diagnosis will involve a synergistic, multimodal approach, combining several early detection methods.

Predictive values of lung cancer alarm symptoms in the general population: a nationwide cohort study

We aimed to firstly determine the 1-year predictive values of lung cancer alarm symptoms in the general population and to analyse the proportion of alarm symptoms reported prior to diagnosis, and secondly analyse how smoking status and reported contact with general practitioners (GPs) regarding lung cancer alarm symptoms influence the predictive values. The study was a nationwide prospective cohort study of 69,060 individuals aged ≥40 years, randomly selected from the Danish population. Using information gathered in a survey regarding symptoms, lifestyle and healthcare-seeking together with registry information on lung cancer diagnoses in the subsequent year, we calculated the predictive values and likelihood ratios of symptoms that might be indicative of lung cancer. Furthermore, we analysed how smoking status and reported contact with GPs regarding the alarm symptoms affected the predictive values. We found that less than half of the patients had reported an alarm symptom six months prior to lung cancer diagnosis. The positive predictive values of the symptoms were generally very low, even for patients reporting GP contact regarding an alarm symptom. The highest predictive values were found for dyspnoea, hoarseness, loss of appetite and for current heavy smokers. The negative predictive values were high, all close to 100%. Given the low positive predictive values, our findings emphasise that diagnostic strategies should not focus on single, specific alarm symptoms, but should perhaps focus on different clusters of symptoms. For patients not experiencing alarm symptoms, the risk of overlooking lung cancer is very low.

The Chest Australia Trial: a randomised controlled trial of an intervention to increase consultation rates in smokers at risk of lung cancer

Background

International research has focused on screening and mass media campaigns to promote earlier patient presentation and detect lung cancer earlier. This trial tested the effect of a behavioural intervention in people at increased risk of lung cancer on help-seeking for respiratory symptoms.

Methods

Parallel, individually randomised controlled trial. Eligible participants were long-term smokers with at least 20 pack-years, aged 55 and above. The CHEST intervention entailed a consultation to discuss and implement a self-help manual, followed by self-monitoring reminders to encourage help-seeking for respiratory symptoms. The control group received a brief discussion about lung health. Both groups had baseline spirometry. Telephone randomisation was conducted, 1:1, stratified Medical Research Council (MRC) dyspnoea score and general practice. Participants could not be blinded; data extraction and statistical analyses were performed blinded to group assignment. The primary outcome was respiratory consultation rates.

Results

We randomised 551 participants (274 intervention, 277 control) from whom the primary outcome was determined for 542 (269 intervention, 273 control). There was a 40% relative increase in respiratory consultations in the intervention group: (adjusted rates (95% CI) intervention 0.57 (0.47 to 0.70), control 0.41 (0.32 to 0.52), relative rate 1.40 (1.08 to 1.82); p=0.0123). There were no significant differences in time to first respiratory consultation, total consultation rates or measures of psychological harm. The incremental cost-effectiveness ratio was $A1289 per additional respiratory consultation.

Conclusions

A behavioural intervention can significantly increase consulting for respiratory symptoms in patients at increased risk of lung cancer. This intervention could have an important role in primary care as part of a broader approach to improve respiratory health in patients at higher risk.

Trial registration number

Australian New Zealand Clinical Trial Registry (1261300039 3752). This was registered pre-results.

Patient and carer perceived barriers to early presentation and diagnosis of lung cancer: a systematic review

Background

Lung cancer is typically diagnosed at a late stage. Early presentation and detection of lung cancer symptoms is critical to improving survival but can be clinically complicated and as yet a robust screening method for diagnosis is not available in routine practice. Accordingly, the barriers to help-seeking behaviour and diagnosis need to be considered. This review aimed to document the barriers to early presentation and diagnosis of lung cancer, based on patient and carer perspectives.

Methods

A systematic review of databases was performed for original, English language articles discussing qualitative research on patient perceived barriers to early presentation and diagnosis of lung cancer. Three major databases were searched: Scopus, PubMed and EBSCOhost. References cited in the selected studies were searched for further relevant articles.

Results

Fourteen studies met inclusion criteria for review. Barriers were grouped into three categories: healthcare provider and system factors, patient factors and disease factors.

Conclusions

Studies showed that the most frequently reported barriers to early presentation and diagnosis of lung cancer reported by patients and carers related to poor relationships between GPs and patients, a lack of access to services and care for patients, and a lack of awareness of lung cancer symptoms and treatment. Addressing these barriers offers opportunities by which rates of early diagnosis of lung cancer may be improved.