What causes delays in diagnosing blood cancers? A rapid review of the evidence

OBJECTIVE

We undertook a rapid review of literature relating to the diagnosis of blood cancers, to find out what factors contribute to delays in diagnosis, including symptom recognition, appraisal and help-seeking behaviours.

METHODS

We used rapid review methodology following Tricco et al. to synthesise current literature from two electronic databases. We searched for studies about symptom appraisal help-seeking for all blood cancers published between 2001 and 2021, written in English.

RESULTS

Fifteen studies were included in the review, of which 10 were published in the United Kingdom. We found a number of factors associated with delays in blood cancer diagnosis. These included patient factors such as gender, age and ethnicity, as well as health system factors such as poor communication and seeing a locum clinician in primary care. A narrative synthesis of the evidence produced four types of symptom interpretation by patients: (1) symptoms compatible with normal state of health, (2) event-linked problems, (3) mild or chronic illness and (4) non-specific unwell state. These four interpretations were linked to different help-seeking behaviours. After seeking help, patients often experienced delays due to healthcare professionals' (HCPs') non-serious interpretation of symptoms, misleading blood tests, discontinuity of care and other barriers in the diagnostic pathway.

CONCLUSION

Blood cancers are difficult to diagnose due to non-specific heterogeneous symptoms, and this is reflected in how those symptoms are interpreted by patients and managed by HCPs. It is important to understand how different interpretations affect delays in help-seeking, and what HCPs can do to support timely follow-up for patients.

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.

Diagnostic delay for head and neck cancer in South India: A Mixed-methods Study

Background:

Early diagnosis is an important aspect of quality of cancer care.Analysis of the diagnostic delays and the reasons for delay helps to plan strategies to improve cancer care.

Objectives:

To determine the primary, secondary, and total diagnostic delay of patients diagnosed with head and neck cancer and to explore the reasons for the delay from the patient perspective.

Methods:

Explanatory mixed method design was used. Two hundred persons with a confirmed diagnosis of head and neck cancer attending the ENT (ear, nose, throat) cancer clinic in a teaching hospital before the initiation of treatment were included in the study. The median delay and the association of the delay with the various factors were analyzed. Sixteen one-to-one interviews of patients were done to identify the reasons for the delays from the patient perspective.

Results:

Median primary, secondary, and total diagnostic delays were 30 days, 30 days, and 73 days, respectively. Statistically, primary delay was found significantly longer among ever users of smokeless tobacco and significantly longer secondary delay was found among those with age less than 60 years. The reasons for the delay were grouped in the categories (i) Symptom appraisal delay due to low perceived seriousness and (ii) health-seeking behavior delay.

Conclusions:

The diagnostic delay was considerable. Measures to enhance symptom appraisal by improving health literacy, opportunistic screening, and strengthening the referral system would decrease diagnostic delay.

Evaluation of a web-based, tailored intervention to encourage help-seeking for lung cancer symptoms: a randomised controlled trial

Background

People with lung cancer often wait for several months before presenting symptoms to health services. Some patients report seeking information online to help them appraise symptoms. No research has evaluated whether websites about lung cancer present information in an optimal manner to encourage help-seeking.

Objective

To evaluate the effectiveness of an online, tailored, theory-based intervention in encouraging help-seeking behaviour among people with potential lung cancer symptoms.

Methods

The intervention consisted of a specialised website which provided tailored information about lung cancer and included a component to address beliefs about help-seeking, based on the Theory of Planned Behaviour (TPB-component). Individuals with undiagnosed symptoms were randomised to receive information about lung cancer in a factorial design (tailored/untailored × TPB-component/no TPB-component). Pre and post viewing webpages, participants reported perceived likelihood of seeking help. Data were analysed using robust mixed factorial ANOVA.

Results

Data from 253 participants (73.9% female) were analysed. No effect for the TPB-component was found (p = 0.16), nor for tailoring (p = 0.27). Self-reported likelihood of seeking help increased significantly from pre to post (p < 0.001), regardless of tailoring and TPB-components.

Conclusion

Self-reported likelihood of seeking help for potential lung cancer symptoms may increase after viewing information online. This does not appear to be affected by information tailoring and components to address beliefs. However, intentions remained unchanged in the majority of the sample. This suggests further efforts are needed to improve lung cancer websites if they are to be a useful resource for those seeking advice about their symptoms.

Lung cancer symptom appraisal among people with chronic obstructive pulmonary disease: A qualitative interview study

OBJECTIVE

The incidence of lung cancer is four times higher in people with chronic obstructive pulmonary disease (COPD) compared with the general population. Promotion of a shorter time from symptom onset to presentation is one potential strategy for earlier lung cancer diagnosis, but distinguishing respiratory symptoms can be difficult. We investigated how the experience of COPD influences symptom appraisal and help seeking for potential lung cancer symptoms.

METHODS

We conducted qualitative interviews with men (n = 17) and women (n = 23) aged 40 to 83 years with COPD. Topic guides drew on the integrated symptom-response framework and covered symptom experience, interpretation, action, recognition, help seeking, evaluation, and reevaluation. We used the framework method to analyse the data.

RESULTS

Participants said that they attributed chest symptoms to their COPD; no other cause was considered. Participants said that family/friends noticed changes in their symptoms and encouraged help seeking. Others felt isolated by their COPD because they could not get out, were fatigued, or were embarrassed. Participants visited health professionals frequently, but increased risk of lung cancer was not discussed.

CONCLUSIONS

Our study provides insight into different levels of influence on symptom appraisal and targets for intervention. Greater awareness of increased lung cancer risk and support to act on symptom changes is essential and could be achieved through a concerted information campaign. Health professionals working with people with COPD could also optimise appointments to support symptom appraisal of potential lung cancer symptoms.

The contribution of a negative colorectal screening test result to symptom appraisal and help-seeking behaviour among patients subsequently diagnosed with an interval colorectal cancer

Background

Colorectal cancer (CRC) screening programmes using a guaiac faecal occult blood test (gFOBt) reduce CRC mortality. Interval cancers are diagnosed between screening rounds: reassurance from a negative gFOBt has the potential to influence the pathway to diagnosis of an interval colorectal cancer.

Methods

Twenty‐six semi‐structured face‐to‐face interviews were carried out in Scotland and England, with individuals diagnosed with an interval colorectal cancer following a negative gFOBt result.

Results

Participants reported they were reassured by a negative gFOBt, interpreting their result as an “all clear”. Therefore, most did not suspect cancer as a possible cause of symptoms and many did not recall their screening result during symptom appraisal. Among those who did consider cancer, and did think about their screening test result, reassurance from a negative gFOBt led some to “downplay” the seriousness of their symptoms with some interviewees explicitly stating that their negative test result contributed to a delayed decision to seek help.

Conclusion

Screening participants need to be informed of the limitations of screening and the ongoing risk of developing colorectal cancer even when in receipt of a negative result: the importance of minimizing delay in seeking medical advice for colorectal symptoms should be emphasized.

The role of social context in symptom appraisal and help-seeking among people with lung or colorectal symptoms: A qualitative interview study

Prolonged diagnostic intervals are associated with poorer outcomes, and the patient interval appears to be a substantial contributor to the overall length of the diagnostic interval. This study sought to understand how the broader context of people's lives influenced symptom appraisal and help-seeking, comparing experiences by length of the patient interval. Patients referred with a suspicion of lung or colorectal cancer were invited to complete a questionnaire about their symptoms, with 26 respondents purposively sampled to take part in a semi-structured interview about their patient intervals. Embodied experience, appraisal, help-seeking decision-making and consultation were identified as component stages of the patient interval, with the factors affecting movement between these stages located in one of four contextual domains: individual experience, interpersonal relationships, healthcare system interactions and social and temporal context. The length of the patient interval was related to the type of symptom(s) experienced, discussion of symptoms with others and the social responsibilities people held during symptomatic periods. A contextual model of the patient interval illustrates the stages and domains of this interval, as grounded in the data from this study. The model has potential application to future studies examining the patient interval for a range of symptoms.

Patient factors influencing symptom appraisal and subsequent adjustment to oesophageal cancer: A qualitative interview study

Oesophageal cancer (EC) is characterised by vague symptoms and is often diagnosed at an advanced stage, leading to poor outcomes. Therefore, we aimed to investigate whether there might be any patient factors contributing to delay in EC diagnosis, and focused on the symptom appraisal and help-seeking strategies of people diagnosed with EC in the UK. Semi-structured interviews were conducted with 14 patients aged >18 years with localised EC at point of diagnosis. Purposive sampling was used to include patients from 1 to 9 months post-diagnosis. Analysis of the interviews identified three main themes: Interpreting symptoms, Triggers to seeking help and Making sense of an unfamiliar cancer. Findings suggested that participants normalised symptoms or used previous health experiences as a means to interpret their symptoms. The majority of participants were not alarmed by their symptoms, mainly because they had very little knowledge of EC specific symptoms. Lack of knowledge also influenced participants' sense-making of their diagnosis. The findings highlight that the process of symptom appraisal in EC is likely to be inaccurate, which may hinder early presentation and thus diagnosis. Public health campaigns communicating EC specific symptoms, however, could shorten the appraisal period and lead to earlier diagnosis.

Symptom appraisal, help seeking, and lay consultancy for symptoms of head and neck cancer

OBJECTIVE

Early diagnosis is important in head and neck cancer (HNC) patients to maximize the effectiveness of the treatments and minimize the debilitation associated with both the cancer and the invasive treatments of advanced disease. Many patients present with advanced disease, and there is little understanding as to why. This study investigated patients' symptom appraisal, help seeking, and lay consultancy up to the time they first went to see a health care professional (HCP).

METHODS

We interviewed 83 patients diagnosed with HNC. The study design was cross sectional and consisted of structured telephone interviews and a medical chart review. We gathered information on the participant's personal reactions to their symptoms, characteristics of their social network, and the feedback they received.

RESULTS

We found that 18% of the participants thought that their symptoms were urgent enough to warrant further investigation. Participants rarely (6%) attributed their symptoms to cancer. Eighty-nine percent reported that they were unaware of the early warning signs and symptoms of HNC. Fifty-seven percent of the participants disclosed their symptoms to at least one lay consultant before seeking help from an HCP. The lay consultants were usually their spouse (77%), and the most common advice they offered was to see a doctor (76%). Lastly, 81% of the participants report that their spouse influenced their decision to see an HCP.

CONCLUSIONS

The results of this study suggest that patients frequently believe that their symptoms were nonurgent and that their lay consultants influence their decision to seek help from an HCP.

Web Use for Symptom Appraisal of Physical Health Conditions: A Systematic Review

Background

The Web has become an important information source for appraising symptoms. We need to understand the role it currently plays in help seeking and symptom evaluation to leverage its potential to support health care delivery.

Objective

The aim was to systematically review the literature currently available on Web use for symptom appraisal.

Methods

We searched PubMed, EMBASE, PsycINFO, ACM Digital Library, SCOPUS, and Web of Science for any empirical studies that addressed the use of the Web by lay people to evaluate symptoms for physical conditions. Articles were excluded if they did not meet minimum quality criteria. Study findings were synthesized using a thematic approach.

Results

A total of 32 studies were included. Study designs included cross-sectional surveys, qualitative studies, experimental studies, and studies involving website/search engine usage data. Approximately 35% of adults engage in Web use for symptom appraisal, but this proportion varies between 23% and 75% depending on sociodemographic and disease-related factors. Most searches were symptom-based rather than condition-based. Users viewed only the top search results and interacted more with results that mentioned serious conditions. Web use for symptom appraisal appears to impact on the decision to present to health services, communication with health professionals, and anxiety.

Conclusions

Web use for symptom appraisal has the potential to influence the timing of help seeking for symptoms and the communication between patients and health care professionals during consultations. However, studies lack suitable comparison groups as well as follow-up of participants over time to determine whether Web use results in health care utilization and diagnosis. Future research should involve longitudinal follow-up so that we can weigh the benefits of Web use for symptom appraisal (eg, reductions in delays to diagnosis) against the disadvantages (eg, unnecessary anxiety and health care use) and relate these to health care costs.

The Role of Web-Based Health Information in Help-Seeking Behavior Prior to a Diagnosis of Lung Cancer: A Mixed-Methods Study

BACKGROUND

Delays to diagnosis in lung cancer can lead to reduced chance of survival, and patients often wait for several months before presenting symptoms. The time between first symptom recognition until diagnosis has been theorized into three intervals: symptom appraisal, help-seeking, and diagnostic interval (here: "pathway to diagnosis"). Interventions are needed to reduce delays to diagnosis in lung cancer. The Web has become an important lay health information source and could potentially play a role in this pathway to diagnosis.

OBJECTIVE

Our overall aim was to gain a preliminary insight into whether Web-based information plays a role in the pathway to diagnosis in lung cancer in order to assess whether it may be possible to leverage this information source to reduce delays to diagnosis.

METHODS

Patients diagnosed with lung cancer in the 6 months before study entry completed a survey about whether (and how, if yes) they had used the Web to appraise their condition prior to diagnosis. Based on survey responses, we purposively sampled patients and their next-of-kin for semistructured interviews (24 interviews; 33 participants). Interview data were analyzed qualitatively using Framework Analysis in the context of the pathway to diagnosis model.

RESULTS

A total of 113 patients completed the survey (age: mean 67.0, SD 8.8 years). In all, 20.4% (23/113) reported they or next-of-kin had researched their condition online before the diagnosis. The majority of searches (20/23, 87.0%) were conducted by or with the help of next-of-kin. Interview results suggest that patients and next-of-kin perceived an impact of the information found online on all three intervals in the time to diagnosis. In the appraisal interval, participants used online information to evaluate symptoms and possible causes. In the help-seeking interval, the Web was used to inform the decision of whether to present to health services. In the diagnostic interval, it was used to evaluate health care professionals' advice, to support requests for further investigation of symptoms, and to understand medical jargon. Within this interval, we identified two distinct subintervals (before/after relevant diagnostic tests were initiated), in which the Web reportedly played different roles.

CONCLUSIONS

Because only 20.4% of the sample reported prediagnosis Web searches, it seems the role of the Web before diagnosis of lung cancer is at present still limited, but this proportion is likely to increase in the future, when barriers such as unfamiliarity with technology and unwillingness to be informed about one's own health are likely to decrease. Participants' perceptions suggest that the Web can have an impact on all three intervals in the pathway to diagnosis. Thus, the Web may hold the potential to reduce delays in the diagnostic process, and this should be explored in future research and interventions. Our results also suggest a division of the diagnostic interval into two subintervals may be useful.

Understanding of a negative bowel screening result and potential impact on future symptom appraisal and help-seeking behaviour: a focus group study

Background

Colorectal cancer (CRC) screening using a faecal occult blood test (FOBt) has the potential to reduce cancer‐related mortality. Symptom vigilance remains crucial as a proportion of cancers will be diagnosed between screening rounds. A negative FOBt has the potential to influence how participants respond to future symptoms of CRC.

Objective

To explore (i) understanding of a negative FOBt and (ii) the potential impact of a negative FOBt upon future symptom appraisal and help‐seeking behaviour.

Design

Qualitative methodology utilizing focus groups with participants who received a negative FOBt within the National Bowel Cancer Screening Programme in Coventry and Lothian. Topics explored included: experience of screening participation, interpretation and understanding of a negative result, symptom awareness and attitudes towards help‐seeking.

Results

Four broad themes were identified: (i) emotional response to a negative FOBt, (ii) understanding the limitations of FOBt screening, (iii) symptom knowledge and interpretation and (iv) over‐reassurance from a negative FOBt. Participants were reassured by a negative FOBt, but there was variability in the extent to which the result was interpreted as an “all clear”. Some participants acknowledged the residual risk of cancer and the temporal characteristic of the result, while others were surprised that the result was not a guarantee that they did not have cancer.

Discussion and conclusions

Participants recognized that reassurance from a negative FOBt could lead to a short‐term delay in help‐seeking if symptoms developed. Screening programmes should seek to emphasize the importance of the temporal nature of FOBt results with key messages about symptom recognition and prompt help‐seeking behaviour.