BrazJOtorhinolaryngol.2016;82(2):140---143
www.bjorl.org
Brazilian
Journal
of
OTORHINOLARYNGOLOGY
ORIGINAL
ARTICLE
Impact
of
delay
in
the
diagnosis
and
treatment
of
head
and
neck
cancer
夽
,
夽夽
André
Wady
Debes
Felippu
a,
Eduardo
Cesar
Freire
a,
Ricardo
de
Arruda
Silva
a,
André
Vicente
Guimarães
b,c,
Rogério
Aparecido
Dedivitis
d,∗aDepartmentofMedicine,FaculdadedeCiênciasdaSaúde,UniversidadeMetropolitanadeSantos(UNIMES),Santos,SP,Brazil bDepartmentofMedicine,UniversidadedeSãoPaulo(USP),SãoPaulo,SP,Brazil
cDepartmentofOtorhinolaryngology,HeadandNeckSurgery,UniversidadeMetropolitanadeSantos(UNIMES),Santos,SP,Brazil dDepartmentofHeadandNeckSurgery,HospitaldasClínicas,UniversidadedeSãoPaulo(USP),SãoPaulo,SP,Brazil
Received3August2014;accepted23February2015 Availableonline6November2015
KEYWORDS
Delayeddiagnosis; Headandneck neoplasms; Squamouscell carcinoma; Timefactors; Primaryhealthcare; Prognosis
Abstract
Introduction:Headandnecktumorscanbeeasilyrecognizedthroughclinicalevaluation. How-ever,theyareoftendiagnosedatadvancedstages.
Objective:Toevaluatethedelayfromthepatient’sinitialsymptomstothedefinitive treat-ment.
Methods:Retrospectivestudyofpatientsenrolledin2011and2012.Aquestionnairewasfilled inaboutsocioeconomicaspects,patienthistory,tumordata,professionalswhoevaluatedthe patients,andtherespectivetimedelays.
Results:Thefollowingtimedelaymedianswereobserved:tenmonthsbetweensymptomonset andthe first consultation;four weeks between thelatter andthe first consultation witha specialist;four weeksbetweenthespecialistconsultationanddiagnosis attainment;and12 weeksbetweendiagnosisandthestartoftreatment.
Conclusions:Mostheadandnecktumorsarediagnosedatadvancedstages,duetopatientand healthcarefactors.
© 2015 Associac¸ão Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Published by Elsevier Editora Ltda. This is an open access article under the CC BY license (https://creativecommons.org/licenses/by/4.0/).
夽
Pleasecitethisarticleas:FelippuAWD,FreireEC,deArrudaSilvaR,GuimarãesAV,DedivitisRA.Impactofdelayinthediagnosisand treatmentofheadandneckcancer.BrazJOtorhinolaryngol.2016;82:140---3.
夽夽Institution:DisciplineofOtorhinolaryngologyandHeadandNeckSurgery,UniversidadeMetropolitanadeSantos(UNIMES),Santos,SP,
Brazil.
∗Correspondingauthor.
E-mail:dedivitis@usp.br(R.A.Dedivitis).
http://dx.doi.org/10.1016/j.bjorl.2015.10.009
Impactofdelayinthediagnosisandtreatmentofheadandneckcancer 141
PALAVRAS-CHAVE
Diagnósticotardio; Neoplasiasdecabec¸a epescoc¸o;
Carcinomadecélulas escamosas;
Fatoresdetempo; Atenc¸ãoprimáriaà saúde;
Prognóstico
Impactodademoranodiagnósticoetratamentonocâncerdecabec¸aepescoc¸o
Resumo
Introduc¸ão: Apesardepoderemserfacilmentereconhecidosaoexameclínico,ostumoresde cabec¸aepescoc¸osão,muitasvezes,diagnosticadosemestadiamentoavanc¸ado.
Objetivo: Avaliarademoraentreosurgimentodossintomasiniciaisdopacienteeseu encam-inhamentoparaotratamentodefinitivo.
Método: Trata-se de um estudo retrospectivo de pacientes arroladosem 2011 e 2012. Foi preenchidoquestionáriosobrefatoressócio-econômicos,antecedentes,dadosdotumor, profis-sionaisqueavaliaramospacienteserespectivosperíodosdedemora.
Resultados: Foramobservadasasseguintesmedianasdetempodedemora:10mesesentreo iníciodossintomaseoprimeiroatendimento;4semanasentreesteeaprimeiraconsultacom oespecialista;4semanasentreestaeoestabelecimentododiagnóstico;e12semanasentre esteeoiníciodotratamento.
Conclusões: A maior partedos cânceres de cabec¸a e pescoc¸o é diagnosticada em estádios avanc¸ados,porfatoresrelacionadosaospacienteseàatenc¸ãoàsaúde.
© 2015 Associac¸ão Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Publi-cado por Elsevier Editora Ltda. Este é um artigo Open Access sob a licença CC BY (https://creativecommons.org/licenses/by/4.0/deed.pt).
Introduction
Head and neck tumors are relatively easy to visualize or palpate at the clinical examination. Nevertheless, many patientsarediagnosedat advancedstages ofthe disease, perhaps duetothelack of earlyalarming symptoms.This resultsinalackofmotivationtoseekmedicalattention.1,2 Headandneckcancersareoftenatanalreadyadvanced stagewhen diagnosed. The greater thedelay in diagnosis andtheonsetoftreatment,themoreadvancedthestage, themoreaggressivethenecessary therapy,andtheworse the prognosis.This makesa fastand efficientdiagnosis a challenge.2Understandingthereasonsresponsibleforlate diagnosisofheadandneckcancercouldhelptodesign inter-ventions aimed at reducing the frequency of unfavorable outcomes.
Ifthe timeperiodbetween theinitialconsultation and treatmentisprolonged,patientsmayexperiencetumorand clinical stage progression, which affects the therapeutic schedulewithpossiblenegativeinfluenceonprognosis.This isarelevantclinicalproblem,ascomorbiditycontrolprior tosurgicaltreatmentmayrequirealongperiod.3
Lesionlocationandthedifferentformsoftumor presen-tation and symptoms may contribute to the delay. Silent tumors, those with difficult access, or those that take longertomanifest obvioussymptoms hinderthepatient’s perception,delayingtheentirediagnosticprocess.4,5 There-fore,veryoften,dependingonthesymptoms,ittakesthe patientlongertoseekmedicalcare.6Studieshavesuggested increasingtheawarenessofindividuals consideredatrisk, such assmokersand drinkers,to seekmedical help after theinitialsymptoms,whichfavorsprognosis.7However,such delaymayalsobeduetofactorsrelatedtoprofessionalcare andhealthcare,withatimeranginginliteraturefromfour daysto3.5months.5
Theaimofthisstudyistoassessthedelayfromsymptom onsettothestart of definitivetreatment, andtoidentify
anyassociationbetweenthedelayandthepatient’s socio-economicstatusandtumorstaging.
Methods
This study wasapproved by the ethics committee of the institution where it was carried out, under No. 730.552. Thisisaretrospectivestudyofnewcasesofsquamouscell carcinoma of the upper aerodigestivetract, diagnosed at theOutpatientClinicofHeadandNeckSurgeryofthe insti-tution, fromJanuary 2011 to August 2012. Tumors of the salivaryglandsandthyroidwereexcludedfromthisstudy, astheyhave differentclinical presentation andbiological behaviorsfromcarcinomaoftheupperaerodigestivetract. Patientscompletedaquestionnairefocusedon epidemi-ological,disease,andtreatmentfactors.Illiteratepatients were aided by an accompanying family member and one oftheauthorswasalwaysavailabletoresolveanydoubts. The following data were collected: identification (name andregistrationnumberattheinstitution),age(inyears), gender, ethnicity, educational level (from none to col-lege/university), smoking and alcohol consumption (both measuredsemi-quantitatively)andprimarytumorlocation. TumorswerestagedaccordingtothesixtheditionoftheTNM classificationof theAmericanJoint Committeeon Cancer (AJCC). The professionals who treated the patient previ-ously, as well as the main modality of cancer treatment thepatientunderwent(surgery,radiotherapy,or palliative chemotherapy)werealsoassessed.
Thefollowingdurationsweremeasured:
1. Intervalbetweenthereportedsymptomonsetand seek-ingmedicalcare(inmonths);
142 FelippuAWDetal.
Table 1 Epidemiological data of the assessed patients (n=80).
n %
Gender
Male 75 93.75
Female 5 6.25
Ethnicity
White 63 78.75
Non-white 17 21.5
Smoking
Regularsmoker 79 98.75
Non-smoker 1 1.25
Alcoholconsumption
Regularuser 42 52.5
Non-user 38 47.5
Levelofschooling
<Elementaryschool 42 52.5
Elementaryschool 32 40
<Highschool 3 3.75
Highschool 3 3.75
Primarysites
Lips 2 2.5
Oralcavity 33 41.25
Oropharynx 8 10
Hypopharynx 5 6.25
Larynx 25 31.25
Paranasalsinuses 3 3.75
Primaryoccult 4 5
Clinicalstaging
ECI 5 6.25
ECII 8 10
ECIII 23 28.75
ECIV 44 55
Mainmodalityofreferral
Surgery 23 28.75
Radiotherapy 52 65
Chemotherapy(palliative) 5 6.25
3. Intervalbetweenthefirstconsultationwiththespecialist andtheattainmentofthediagnosis--- anatomopatholog-icalresults(inweeks);
4. Intervalbetweendiagnosis attainmentandstart ofthe treatment(inweeks).
Results
Ofthe80patientsidentified,75weremales(93.75%),and 63 werewhite (78.75%).Age ranged from45to 73years, withamedianof63years.Mostofthemregularlyconsumed tobaccoproducts(98.75%)andalcohol(52.5%).Asfor edu-cationallevel,mosthadnotfinishedelementaryschool:42 (52.5%). Among the tumor sites, the most frequent ones wereoralcavity,33(41.84%),andlarynx,25(31.25%).The distributionoftheinitialclinicalstagesshoweda predomi-nanceofECIII,23(28.75%)andECIV,44(55%)(Table1).
All 80 patients underwent a consultation with a non-specialistinheadandnecksurgery:45withan otorhi-nolaryngologist,38withageneralist,12withadentist,and eight with other specialties, i.e., three patients went to threedifferent professionals beforehaving a consultation withtheexpert,and14hadaconsultationwithtwodifferent professionalsbeforehand.
The median timebetween symptom onsetand seeking medical care was ten months; four months between the firstgeneralconsultation motivatedby thetumor andthe first visit to the specialist; between the latter and diag-nosisattainment, fourmonths;andbetweenthediagnosis attainmentandstartofthetreatment,12months(withno differencebetweenthemaintreatmentmodalitiestowhich patientswerereferredto)(Table2).
Discussion
There is aconsensusthat theprognosis of headand neck canceratadvancedstages(ECIIIandIV)isworsethanthat observedintumorsdiagnosedintheearlystages.Anydelay indiagnosisandtreatmentcanleadtoaprogressiontomore advancedstages,andthusadecreaseincureratesand treat-menteffectiveness.3Iftheadvanceddiseaseistheresultof the delay in case presentation or management,it can be concludedthatthereductionofsuchintervalwouldleadto treatmentatanearlierstage,increasingsurvivalratesand reducingmorbidity.4
Thedelayindiagnosisreferstothetotalperiodoftime between symptom onsetandwhen thediagnosis is estab-lished.Fromthenuntilthestartofthetreatment,thedelay occursintreatmentplanningandperformance.Onecanalso divide the delay into twophases: the periodfrom symp-tom onsetto the seekingof medical care (patientdelay) andtheexcessivetimebetweenthefirstconsultationwith ahealthprofessionalandthefirstconsultationwitha spe-cialist(healthsystemdelay).8Thisdelaybytheprofessional couldalsobedefinedasthetimebetweenthefirst medi-calconsultation(usuallywithanon-specialist)andthedate
Table2 Medianandrangeoftheintervalsstudied(n=80).
Interval Median Range
Symptomonset---seekinghealthcareservice(months) 10 8---48
Firstconsultationwithageneralpractitioner---firstconsultationwithaspecialist(weeks) 4 2---180 Firstconsultationwithaspecialist---establishingthediagnosis(weeks) 4 2---8
Impactofdelayinthediagnosisandtreatmentofheadandneckcancer 143
ofthehistopathologicaldiagnosis.Whileprofessionaldelay canbemeasuredrelativelyaccurately,patientdelaytends toshowassessmenterror, asit dependsonitsdegree and perception.9
It isbelievedthat alongerperiodfromsymptom onset todiagnosis confirmation wouldexplain the fact that the disease is diagnosed at advanced stages.8 Patient delay in seeking medical care can be due to factors related to the tumor, such as the primary tumor site and its characteristics,sometimesoligosymptomatic.Additionally, sociodemographicvariables,suchassocioeconomicstatus, can influence delay. Psychological factors must also be considered.6
In the present series, treated at a public outpatient clinic,themediantimeofsymptomonsettomedical consul-tationwastenmonths.Thisdelaycanbe,inpart,attributed tospecificpatientfactors.1,2 The population’sdifficultyin accessingaspecialistseemstobedueinparttotheirlow socioeconomicstatus.Sometimestheylackfundsevenfor the use of public transport. Patient delay, as mentioned before,isdifficulttomeasureaccuratelybecauseitisbased onperception,whichishighlysubjectiveandcanbe influ-enced by many social and cultural factors.9 Additionally, when considering the entire case management, patients shouldalsobe carefully instructedabout the returnvisits andfollow-up.1
Inthepresentstudy,themediantimeforapatienttobe referredfromprimarycaretoaspecialist (headand neck surgeon)wasfourweeks.Oneoftherelativelyquickfactors wasthefact thatthe initial evaluationwasconductedby anotorhinolaryngologist,whorecognizedthesituationand referredthepatienttothecancerspecialist.
However, it took some patients a long time tohave a consultation withthe head and neck surgeon,and in this case,theauthorsmainlyrecognizethelackofself-careon the part of most of these patients, who neglected their condition. However,otherpatients experienceda relative delaybecauseoftheprofessionalsinvolved,asthepatients had more than one consultation before the appointment withthespecialist. Indeed,somegeneralhealth care pro-fessionalsfailedtorecognizecertainsignsandsymptomsas suggestiveofmalignancy.
There are many problems involving delay in diagnosis, especiallyinthepublichealthcaresystem;there,aprompt initiation of an indicated treatment, including surgery, is notalwayspossible.Itisnotonlytheintellectualandsocial statusofthepatientthatimpactsthedifficultyintreating head andneckcancer, but alsothemany shortcomingsof thepublichealthcareservice,includingreferral,scheduling testsandtreatment.
Studies have documentedlowersurvival rates in popu-lationswithapoorersocioeconomicstatus.10 Thisreflects the occurrence of more advanced tumors in this group due,inpart,tothelackofeducation(withlimiteduseof preventivebehaviorsforhealth), delayinseekingmedical care,andthereality ofinsufficientmedicalcare.9Evenin cases oftumors whose locationwould facilitate the diag-nosis---suchasoralcancer---thereisatendency todelay, attributedtopatientfactors,aswellashealthprofessional factors---physicians and dentists.11 Much time is also lost
waiting for the scheduling of more sophisticated imaging methods,oftenimportantfortumorstaging,acrucialstep todefinethetherapeuticstrategytobeused.
Aftertheanatomopathological diagnosis isestablished, themediantime tothe start oftreatment was12weeks. This delay occurred irrespective of the main therapeutic modalityforwhichthepatientwasreferred(surgery, radi-ationtherapy,orpalliativechemotherapy),asitrepresents thecurrent globalrealityofthepublichealthcaresystem patientin Brazil.This timeincludes theschedulingofthe firstconsultationandtreatmentplanning.
Conclusion
Most head and neck malignant tumors are diagnosed at advanced stages. Delay occurred in all periods, both for diagnosis and treatment, due to both patient as well as healthcarefactors.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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