Head and neck cancer in primary care: presenting symptoms and the effect of delayed diagnosis of cancer cases

Abstract

Research H ead and neck cancer usually manifests as squamous cell carcinomas of the upper aerodigestive tract.1 The rates of death associated with head and neck cancer continue to be high (a 5-year relative survival rate of 33%-62% according to the site of the tumour) because the disease is often undiagnosed until it is at an advanced stage. [2][3][4] Whether and to what extent this is due to failures in the initial diagnosis in primary care is unknown.The research on head and neck cancer has generally lacked a primary care perspective. Statistics describing the overall occurrence of cases (e.g., they constitute about 5% of all cancers in the West; some 40 000 new cases occur each year in the United States)1,5 fail to give a good idea of how often a general practitioner sees a new case. Similarly, the main symptoms are well known, 1,6 but how often they occur is not. Misdiagnoses are frequent, 7-9 but it is unclear whether this is because physical examination of the region is technically demanding, particularly the laborious indirect visualization of the nasopharynx and larynx with small mirrors.10 Finally, it is also unclear whether an initial misdiagnosis leads to poorer outcomes. Attempts to link long delays in diagnosis with advanced stages of the disease or poor survival have had conflicting results. 8,11-14We sought to investigate the diagnosis of head and neck carcinoma in primary care by performing 2 studies. In a crosssectional questionnaire study, we explored the frequency of symptoms associated with head and neck carcinoma. In a population-based cohort of 221 patients, we sought answers to the following questions: How often does a general practitioner see a new case? How are the patients examined? And, finally, does the outcome of the initial visit affect survival? MethodsIn the questionnaire study, we used cross-sectional data 15 to gather information on the frequency of the symptoms of head and neck cancer in primary care in Finland. A total of 25 health centres were randomly selected throughout Finland (4 in cities, 5 in smaller towns and 16 in rural communities). Altogether, 28 primary care physicians from these centres took part in a 4-week study, for 1 week in each of the 4 seasons in 1996. Age, sex and the primary presenting symptom16 were recorded for all patient visits except visits received out of regular business hours.In the cohort study, we used a population-based retrospective cohort design to collect data on the cancer patients. The area where the cancer patients were identified comprises 87 communities (total population about 700 000), which maintain one primary health care centre each and 4 central hospitals and one university hospital collectively. According to the Finnish Medical Association, there were 520 physicians and 1 502 800 visits for primary care services in the study area in 1996. All of the patients in whom tongue, pharyngeal or laryngeal cancer Head and neck cancer in primary care: presenting symptoms and the effect of delayed diagnosis of cancer cases Background: Little...

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“…Unfortunately however a comparison of waiting times for other symptoms such as prolonged pain or numbness was not incorporated. 57 Patients afflicted with oral cancer are often of low socioeconomic background and financial barriers may play an important role in patient delay. 55 Practitioners agreed that patients of low socioeconomic background exhibited greater delay.…”

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“…13 It is estimated that 5-15% of the population have an oral lesion at any one time, but very few of these lesions have any malignant potential. 14 If all these 'possible cancers' were referred to the secondary care services for evaluation the hospital services could not cope.…”

“…The practical application of these facts is illustrated by a study of 25 health centres in Finland where age, sex and primary presenting symptoms were recorded for 5,646 patient visits. 13 The data show that a primary care physician will encounter on average two new cases of head and neck cancer during their entire career which translates into 63,000 patient visits for one tumour to be detected. A similar situation pertains to dentists.…”

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