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

Abstract

Background: Little is known about “within-patient delay”, 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 and Setting: Newly diagnosed lung cancer oncology patients 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 and 241 days (61.4% and 78.5% of total delay respectively). 38.8% patients felt they had delayed. Patient-related causes of delay were denial (ratio of means (ROM) 4.36, p=0.002, 95% CIs 1.71-11.1), anxiety (3.36, 0.026, 1.16-9.76), non-recognition of symptoms (2.80, 0.004, 1.41-5.59) and smoking (1.76, 0.021, 1.09-2.86), respectively. These symptoms were associated with delay: finger swelling/discomfort (ROM=2.72, p=0.009, CIs 1.29-5.74), cough (2.53, <0.001, 1.52-4.19), weight loss (2.41, <0.001, 1.49-3.88), weakness (2.35, 0.001, 1.45-3.83), dyspnoea (2.30, 0.001, 1.40-3.80), voice change (1.90, 0.010, 1.17-3.10) and sputum (1.66, 0.039, 1.03-2.67), respectively, also having more than five symptoms (compared to 1-3) (3.69, <0.001, 2.05-6.64). 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 ever-smokers regarding their symptoms, to ensure early referral to secondary care.

Illness Denial in Medical Disorders: A Systematic Review

“…In a more recent study, Panzarella et al [149] found that illness denial was a significant predictor of diagnostic delay in patients with oral squamous cell carcinoma. Similarly, in a cohort study of newly diagnosed patients with lung cancer, Kotecha et al [150] found that illness denial was one of the most significant patient-related causes of delay (defined as the time from first symptoms of lung cancer to contacting primary care). Contrasting results were also reported.…”

“…In another study with post-myocardial infarction patients, illness denial was found to be associated with an increased risk of being non-adherent to medications [44]. Among patients with lung cancer, illness denial was one of the most significant causes of delay in seeking medical help [150]. In these cases, where illness denial inhibits actions of potential importance (e.g., refusal of medical attention or poor compliance with necessary treatment), it should be regarded as maladaptive [16, 19].…”

Incidental pulmonary nodules may lead to a high proportion of early-stage lung cancer: but it requires more than a high CT volume to achieve this

“…The hypothesis could not be substantiated in the current study, making it more likely that the reason for the less favorable stage distribution and lower survival rates of lung cancer patients in Region Zealand is not related to different hospital management practices across regions, but rather to regional differences in pre-hospital delays corresponding to the significantly lower proportion of stage IV patients with a prior CT scan in Region Zealand compared with the other hospitals. Previous studies have found substantial patient-related delays with a mean of 188 days [ 21 , 22 ]. As much as 38.8% of patients felt they had delayed lung cancer investigation, and the major reasons for delay were denial, anxiety, and non-recognition of symptoms.…”

Social inequality and barriers to healthcare-seeking with lung cancer symptoms – a population-based study

“…Other patients with lung cancer describe how they feared receiving a smoking related diagnosis resulting in immediate healthcare-seeking for some and postponing healthcare-seeking for others 29 . Current knowledge about barriers to healthcare-seeking with lung cancer symptoms is based on research among lung cancer patients 30,31 or on studies exploring anticipated barriers to healthcare-seeking 32 , which might be biased and difficult to apply to the understanding of the healthcare-seeking behaviour in the general population. Despite improvements in treatments and prognosis, more knowledge about barriers to healthcare-seeking with lung cancer symptoms is needed to improve early diagnosis and lung cancer survival rates.…”