Delay in diagnosis and its effect on outcome in head and neck cancer

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Summary

We examined the records of two cohorts of patients who were seen from 1960 to 1999 with a diagnosis of squamous cell carcinoma (SCC) of the mouth and throat, one series being retrospective (n = 400) and the other prospective (n = 213) to find out about delays in diagnosis.

The median delay in both cohorts was 3 months and the patients were responsible for the delay in most cases (n = 319, 81% and n = 160, 78%, respectively). Half the patients in each cohort had delayed diagnoses (n = 217, 54% and n = 119, 56%, respectively) and similar percentages (n = 110, 53% and n = 172, 47%) presented with advanced disease (stage III or IV). These were not the same patients for there was no correlation between delay and stage or survival. Logistic regression analysis showed that non-white race (p = 0.01) and high-grade histology (p = 0.002) predicted advanced disease. The proportion of patients presenting with advanced disease had not changed in 40 years despite public education. We suggest that some tumours may be silent and that initial symptoms do not reliably predict early disease.

Introduction

It is easy to presume that delay in diagnosis results in a larger cancer and a reduction in survival. It is on this premise that the policy was founded to educate the public on the dangers of delay in seeking advice. The success of this policy is anticipated by the fact that the single most important factor that influences the prognosis of head and neck cancer is the stage of the disease at presentation. The 5-year survival for small tumours approaches 80% but falls to 30% for stage IV disease.1, 2, 3 If advanced disease is the result of delay in presentation, then it follows that without such a delay the disease could be treated earlier in its development, with improved survival and reduced morbidity. Our aim was to establish if there is a positive correlation between increased delay in diagnosis and advanced stage at presentation of mouth and throat cancers.

Section snippets

Patients and methods

The data are based on the records of two cohorts of patients with squamous cell carcinoma (SCC) of the mouth or throat who were treated between 1960 and 1999. The first were the records of a series of 930 consecutive patients treated between 1961 and 1986 at a district general hospital. Data on delay in presentation were available in 695, of whom we selected 400. The second was a prospective series of 366 consecutive patients with head and neck cancer treated at a cancer centre from 1992 to

Results

The mean age of the patients was 61 years in the retrospective series (range, 2–99) and 60 years in the prospective series (range, 16–95). The male:female ratio was 1.6:1. The median period of delay in both cohorts was 3 months. The proportion of patients with delay (retrospective series n = 198, 50% and prospective series n = 116, 57%) and advanced disease (retrospective series n = 184, 46% and prospective series n = 112, 54%) was similar and remained essentially unchanged over the 40 years. The

Discussion

It seems obvious that the longer a patient waits from the start of a cancer to diagnosis, the more advanced the cancer will be and the worse the prognosis. But when delay was defined as the period between recognition of symptoms and diagnosis, we found no correlation between delay and either stage of disease at presentation or survival. This is unlikely to be a chance observation as it has been reported in nine other studies.6, 7, 8, 9, 10, 11, 12, 13, 14 However, why is there no correlation

Conclusions

The incidence of delay in diagnosis and advanced disease for mouth and throat cancer has not altered during the past 40 years. Delay correlates with neither the stage of tumour at presentation nor survival. The most likely explanation is that some tumours are relatively silent until they are advanced.

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