Delays in Diagnosis of Head and Neck Cancers
• Thomas Yu, DMD, MSc, FRCD(C) •
• Robert E. Wood, DDS, MSc, PhD, FRCD(C) •
• Howard C. Tenenbaum, DDS, Dip Perio, PhD, FRCD(C) •
A b s t r a c t
Delays in diagnosis of head and neck cancer involve 2 periods. The time from onset of symptoms to the initial visit to a dental or medical professional is known as “patient delay.” “Professional delay” is the time during which the patient is under professional care until a confirmed histological diagnosis is made. The “total delay” is the sum of patient plus professional delay. The objectives of this study were to estimate patient, professional and total delay and to identify factors that might influence the length of the delay.
Materials and Methods: Factors associated with diagnostic delay among head and neck cancer patients presenting to Princess Margaret Hospital (Toronto, Ontario) were evaluated from September 2005 to September 2006. Patients were asked to report the first signs or symptoms noticed. The initial action (e.g., antibiotic treatment, referral)
was the decision made by the clinician initially following this first contact. Patients were asked if they had annual dental checkups. Risk marker data included demographic and socioeconomic characteristics, as well as information on tobacco and alcohol use. Dates of biopsies and confirmed histopathologic diagnoses were also recorded. Median values were calculated for patient, professional and total delay. Patients with delays above the median value were considered “delay groups,” while those with values below the median were classified as “non-delay” groups. Variables were analyzed to determine any significant relation to patient, professional or total delay.
Results: In all, 105 patients were interviewed; 3 were excluded because of incomplete information or lack of consent leaving 102 patients (63 males and 39 females). Following initial consultation, most practitioners referred patients to a specialist (38.2%), although some practitioners did not feel that any further investigation or treatment was necessary (12.7%). Approximately two-thirds of patients saw their dentist for regular checkups. Most patients had a history of smoking (median 20 cigarettes a day for 35 years). Median patient delay was 4.5 weeks, whereas median professional delay was 11.8 weeks. Median total delay was 22.5 weeks. Women tended to have significantly longer total delays than men (p < 0.01). When practitioners decided to refer immediately, delays in diagnosis were dramatically reduced compared with cases where no referral was recommended, which led to significantly longer professional delay (p < 0.001). If patients were not under the regular supervision and care of a dentist, they were more likely to have longer patient delays (p < 0.05). Patients who were non-smokers tended to have longer professional delays compared with smokers (p < 0.05).
Discussion: Early head and neck cancers are often subtle or asymptomatic. The median total delay of nearly 6 months was longer than expected. Therefore, it is important for the clinician to maintain a universally high index of suspicion, regardless of risk factors such as tobacco or alcohol use. If there are signs of potential malignancy, health care professionals must promptly make an appropriate referral for diagnosis. Furthermore, the foundation for improving this situation must include education of the public.
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