Patient factors influencing symptom appraisal and subsequent adjustment to oesophageal cancer: A qualitative interview study

Oesophageal cancer (EC) is characterised by vague symptoms and is often diagnosed at an advanced stage, leading to poor outcomes. Therefore, we aimed to investigate whether there might be any patient factors contributing to delay in EC diagnosis, and focused on the symptom appraisal and help‐seeking strategies of people diagnosed with EC in the UK. Semi‐structured interviews were conducted with 14 patients aged >18 years with localised EC at point of diagnosis. Purposive sampling was used to include patients from 1 to 9 months post‐diagnosis. Analysis of the interviews identified three main themes: Interpreting symptoms, Triggers to seeking help and Making sense of an unfamiliar cancer. Findings suggested that participants normalised symptoms or used previous health experiences as a means to interpret their symptoms. The majority of participants were not alarmed by their symptoms, mainly because they had very little knowledge of EC specific symptoms. Lack of knowledge also influenced participants’ sense‐making of their diagnosis. The findings highlight that the process of symptom appraisal in EC is likely to be inaccurate, which may hinder early presentation and thus diagnosis. Public health campaigns communicating EC specific symptoms, however, could shorten the appraisal period and lead to earlier diagnosis.     

Time intervals in the care pathway to cancer diagnosis during the COVID-19 pandemic: A large retrospective study from a high-volume center

Despite extensive research on cancer care during the COVID-19 pandemic, evidence on the impact on prediagnostic time intervals is lacking. To better understand how COVID-19 changed the pathway to diagnosis of cancer, we examined the length of intervals from symptom onset to diagnosis for 13 common cancer types with known clinical stage over 1-year nonpandemic period (March 2019 to March 2020; N = 844) and three biannual COVID periods (March 2020 to September 2021; N = 1172). We analyzed the patient interval (from first symptoms to presentation to a physician), the primary care/emergency department interval (from presentation with relevant symptoms to a primary care or emergency department physician to referral to a hospital-based diagnosis center) and the hospital interval (from referral to diagnosis). Compared to nonpandemic data, there were significant changes across COVID periods. The pandemic mostly impacted patient intervals for cancers diagnosed over the first 6 months after onset in March 2020. Overall median patient intervals were longest in the early COVID period (39 [IQR 22-64] days) and shortest in the nonpandemic period (20 [IQR 13-30] days; Kruskal-Wallis test [χ²], P < .0001). Differences in clinical stage between periods were relevant, with cancers from the mid-period (September 2020 to March 2021) showing the most advanced stage. A shift to later stage was plausibly a result of delayed intervals in the early COVID period. Since intervals are eventually relevant to prognosis, our results provide a baseline against which the impact of improvement strategies to minimize the negative outcomes of COVID-19-associated cancer delays can be assessed and implemented.     

Variation in promptness of presentation among 10,297 patients subsequently diagnosed with one of 18 cancers: Evidence from a National Audit of Cancer Diagnosis in Primary Care

Cancer awareness public campaigns aim to shorten the interval between symptom onset and presentation to a doctor (the ‘patient interval’). Appreciating variation in promptness of presentation can help to better target awareness campaigns. We explored variation in patient intervals recorded in consultations with general practitioners among 10,297 English patients subsequently diagnosed with one of 18 cancers (bladder, brain, breast, colorectal, endometrial, leukaemia, lung, lymphoma, melanoma, multiple myeloma, oesophageal, oro‐pharyngeal, ovarian, pancreatic, prostate, renal, stomach, and unknown primary) using data from of the National Audit of Cancer Diagnosis in Primary Care (2009–2010). Proportions of patients with ‘prompt’/‘non‐prompt’ presentation (0–14 or 15+ days from symptom onset, respectively) were described and respective odds ratios were calculated by multivariable logistic regression. The overall median recorded patient interval was 10 days (IQR 0–38). Of all patients, 56% presented promptly. Prompt presentation was more frequent among older or housebound patients (p < 0.001). Prompt presentation was most frequent for bladder and renal cancer (74% and 70%, respectively); and least frequent for oro‐pharyngeal and oesophageal cancer (34% and 39%, respectively, p <.001). Using lung cancer as reference, the adjusted odds ratios of non‐prompt presentation were 2.26 (95% confidence interval 1.57–3.25) and 0.42 (0.34–0.52) for oro‐pharyngeal and bladder cancer, respectively. Sensitivity analyses produced similar findings. Routinely recorded patient interval data reveal considerable variation in the promptness of presentation. These findings can help to prioritise public awareness initiatives and research focusing on symptoms of cancers associated with greater risk of non‐prompt presentation, such as oro‐pharyngeal and oesophageal cancer.     

Evidence of increasing mortality with longer diagnostic intervals for five common cancers: A cohort study in primary care

BackgroundEarly diagnosis is considered a key factor in improving the outcomes in cancer therapy; it remains unclear, however, whether long pre-diagnostic patient pathways influence clinical outcomes negatively. The aim of this study was to assess the association between the length of the diagnostic interval and the five-year mortality for the five most common cancers in Denmark while addressing known biases.MethodsA total of 1128 patients with colorectal, lung, melanoma skin, breast or prostate cancer were included in a prospective, population-based study in a Danish county. The diagnostic interval was defined as the time from the first presentation of symptoms in primary care till the date of diagnosis. Each type of cancer was analysed separately and combined, and all analyses were stratified according to the general practitioner’s (GP’s) interpretation of the presenting symptoms. We used conditional logistic regression to estimate five-year mortality odds ratios as a function of the diagnostic interval using restricted cubic splines and adjusting for comorbidity, age, sex and type of cancer.ResultsWe found increasing mortality with longer diagnostic intervals among the approximately 40% of the patients who presented in primary care with symptoms suggestive of cancer or any other serious illness. In the same group, very short diagnostic intervals were also associated with increased mortality. Patients presenting with vague symptoms not directly related to cancer or any other serious illness had longer diagnostic intervals and the same survival probability as those who presented with cancer suspicious/serious symptoms. For the former, we found no statistically significant association between the length of the diagnostic interval and mortality.ConclusionIn full coherence with clinical logic, the healthcare system instigates prompt investigation of seriously ill patients. This likely explains the counter-intuitive findings of high mortality with short diagnostic intervals; but it does not explain the increasing mortality with longer diagnostic intervals. Thus, the study provides further evidence for the hypothesis that the length of the diagnostic interval affects mortality negatively.     

Identifying predictors of delayed diagnoses in symptomatic breast cancer: a scoping review

Delayed diagnosis of breast cancer can adversely impact patient outcomes. To better understand this issue, we conducted a scoping review of literature from 1996 to 2015 that examined predictors of delayed presentation and diagnosis among women with breast cancer symptoms. We performed searches to identify studies of predictors of the time from symptom onset to first presentation (the patient interval), first presentation to diagnosis (the diagnostic interval) and symptom onset to diagnosis (the total interval) among women with breast cancer symptoms. Two reviewers independently reviewed and abstracted the findings of these studies. Of the 22 studies included in this review, 16 examined predictors of the patient interval, six examined predictors of the diagnostic interval and four examined predictors of the total interval. A total of 116 predictors were examined; three had evidence of an association with a less timely diagnosis: not disclosing symptoms to others, non‐lump breast symptoms and African American ethnicity. Improving awareness of atypical breast cancer symptoms and encouraging disclosure could improve the timeliness of a breast cancer diagnosis. Access concerns for vulnerable groups need to be addressed. Future research should be more purposeful in its choice of predictors, possibly through the use of established conceptual frameworks.     

Predictors of the interval between onset of symptoms and first medical visit in patients with digestive tract cancer

Lack of effective population screening programmes for digestive tract cancer makes a prompt diagnosis of symptomatic patients the primary option for early detection. The objective of the study was to analyze the characteristics and determinants of the interval between the first medical symptom and the first medical visit (ISV) in a sample of symptomatic patients of mid-low socioeconomic level admitted to hospital for a digestive tract cancer. During two years, 183 patients were personally interviewed with a structured questionnaire designed to elicit initial symptoms of digestive cancer. Fifty-seven percent consulted a physician during the first month after onset of symptoms, and over two-thirds did so within the first 2 months, but it took more than 3 months for 22.4% of the patients. In univariate analyses, the ISV was longer among patients illiterate, unemployed and in the lower social classes. The interval was also significantly longer when the physician-interviewer judged that the patient did not correctly identify the first symptom (p<0.05). In multivariate analyses, the chance of a longer ISV was 2.8 times higher in men; 16 times higher in unemployed patients; 9 times higher in patients with a first symptom of the lower digestive tract; and it increased 8-fold in subjects who attributed no importance to the first manifestation (all p<0.05). In spite of virtually universal health coverage, social factors seemed to act as barriers to seeking medical help in a subgroup of patients. Their procrastination was also related to the nature of the initial symptoms. Achieving an early clinical detection of digestive cancers may be difficult in some segments of the population, and may require substantial improvements in access to and the efficiency of the health system.     

Patient delay in oral cancer: a qualitative study of patients' experiences

Up to 30% of patients delay seeking the advice of a healthcare professional after self-discovery of symptom(s) of oral cancer. Reasons for this patient delay are poorly understood. The aim of the present study was to explore patients' initial experiences and reactions to developing symptoms of oral cancer, and to identify factors influencing their decision to consult a health care professional. In-depth semi-structured interviews were conducted with 17 consecutive patients who had received a diagnosis of oral squamous cell carcinoma, but had yet to start treatment. Participants were asked about their beliefs about their symptoms over the course of the disease and their decision to seek help. The tape-recorded interviews were transcribed verbatim and analysed using 'Framework analysis'. Oral symptoms were rarely attributed to cancer and were frequently interpreted as minor oral conditions. As a result of these beliefs, patients tended to postpone seeking help or fail to be concerned over their symptoms. Prior to seeking help, patients responded to symptoms by using self-medication, changing the way they ate and disclosing their discovery of symptoms to friends or family. Problems with access to healthcare professionals and patients' social responsibilities acted as barriers to prompt help-seeking. This study has documented that an individual's interpretation of oral cancer symptoms may be misguided and this can adversely affect subsequent help-seeking behaviour.     

Coping Strategies and Patient Delay in Patients with Cancer

This study examined associations between avoidance and approach coping and patient delay in cancer patients (N = 1024). Approach coping was associated with short appraisal intervals (time from symptom discovery to recognition of symptom seriousness). Avoidance coping was associated with long appraisal intervals when adjusting for covariates. Help-seeking intervals (time from recognition of symptom seriousness to contact to general practitioner) were only associated with approach coping and only when adjusting for the influence of covariates. The results revealed a complex relationship between coping and patient delay and supported that normal processing of health threats implies avoidance and approach coping strategies.     

Antecedents of domain-specific quality of life after colorectal cancer

Objective: The present study prospectively assessed the influence of medical, socio‐demographic, psychological, and lifestyle variables on physical, social/family, emotional, functional well‐being and colorectal cancer‐specific concerns in a population‐based sample of colorectal cancer survivors. Methods: Participants (n=1822) were assessed at 6 and 24 months post‐diagnosis. Predictor variables assessed at 6 months included socio‐demographic and medical variables, symptoms/side‐effects, body mass index, physical activity, optimism, social support, and cancer threat appraisal. Quality of life (QOL) was assessed at 6 and 24 months post‐diagnosis using the Functional Assessment of Cancer Therapy ‐ Colorectal (FACT‐C). Results: For each QOL subscale and for the overall FACT‐C scale, 6 month scores were the strongest predictor of QOL scores at 24 months post‐diagnosis (e.g. β=0.447, p < 0.001 for overall QOL). Socio‐demographic, medical, and psychosocial variables, but not lifestyle variables, differentially predicted domain specific QOL. Only cancer threat appraisal was associated with all five QOL domains. Conclusion: Cancer threat appraisal presents as a potentially modifiable variable for interventions seeking to improve QOL. Symptom management and lifestyle strategies to ameliorate the effects of co‐morbidities, disease stage and troublesome symptoms such as faecal incontinence on QOL should also be included. Copyright © 2008 John Wiley & Sons, Ltd.     

The symptom interval in children and adolescents with soft tissue sarcomas

BACKGROUND:

In a series of 575 patients ≤21 years of age with soft tissue sarcomas (STSs), the authors investigated the association patterns between symptom interval (ie, the period between the onset of the first symptoms or signs of the disease and its definitive diagnosis) and patient/tumor characteristics or disease outcome (in terms of survival).

METHODS:

The analysis was based on multivariate models (linear for associations with patient/tumor characteristics and Cox's for survival).

RESULTS:

The symptom interval ranged between 1 week and 60 months (median, 2 months) and tended to be longer the older the patient (ie, the interval was longer in adolescents than in children) and the larger the tumor's size, and for tumors located at the extremities and for nonrhabdomyosarcoma STSs (as opposed to rhabdomyosarcomas). A longer symptom interval unfavorably influenced survival (P = .002), which was also significantly affected by the patient's age and the size and surgical stage of the tumor. A different pattern of association between symptom interval and survival emerged for different types of STS histology.

CONCLUSIONS:

Our study points to an independent prognostic effect of symptom interval that cannot be explained by its associations with other factors, such as patient's age or the site, size, stage, and histology of the tumor. Future studies should focus more on the possible causes of symptom interval in pediatric STS populations to enable corrective measures to be implemented to reduce the diagnostic delay. Cancer 2010. © 2010 American Cancer Society.     

Comparison of cancer diagnostic intervals before and after implementation of NICE guidelines: analysis of data from the UK General Practice Research Database

Background:

The primary aim was to use routine data to compare cancer diagnostic intervals before and after implementation of the 2005 NICE Referral Guidelines for Suspected Cancer. The secondary aim was to compare change in diagnostic intervals across different categories of presenting symptoms.

Methods:

Using data from the General Practice Research Database, we analysed patients with one of 15 cancers diagnosed in either 2001–2002 or 2007–2008. Putative symptom lists for each cancer were classified into whether or not they qualified for urgent referral under NICE guidelines. Diagnostic interval (duration from first presented symptom to date of diagnosis in primary care records) was compared between the two cohorts.

Results:

In total, 37 588 patients had a new diagnosis of cancer and of these 20 535 (54.6%) had a recorded symptom in the year prior to diagnosis and were included in the analysis. The overall mean diagnostic interval fell by 5.4 days (95% CI: 2.4–8.5; P<0.001) between 2001–2002 and 2007–2008. There was evidence of significant reductions for the following cancers: (mean, 95% confidence interval) kidney (20.4 days, −0.5 to 41.5; P=0.05), head and neck (21.2 days, 0.2–41.6; P=0.04), bladder (16.4 days, 6.6–26.5; P⩽0.001), colorectal (9.0 days, 3.2–14.8; P=0.002), oesophageal (13.1 days, 3.0–24.1; P=0.006) and pancreatic (12.6 days, 0.2–24.6; P=0.04). Patients who presented with NICE-qualifying symptoms had shorter diagnostic intervals than those who did not (all cancers in both cohorts). For the 2007–2008 cohort, the cancers with the shortest median diagnostic intervals were breast (26 days) and testicular (44 days); the highest were myeloma (156 days) and lung (112 days). The values for the 90th centiles of the distributions remain very high for some cancers. Tests of interaction provided little evidence of differences in change in mean diagnostic intervals between those who did and did not present with symptoms specifically cited in the NICE Guideline as requiring urgent referral.

Conclusion:

We suggest that the implementation of the 2005 NICE Guidelines may have contributed to this reduction in diagnostic intervals between 2001–2002 and 2007–2008. There remains considerable scope to achieve more timely cancer diagnosis, with the ultimate aim of improving cancer outcomes.     

The influence of social factors on help‐seeking for people with lung cancer

While there has been no clear consensus on the potential for earlier diagnosis of lung cancer, recent research has suggested that the time between symptom onset and consultation can be long enough to plausibly affect prognosis. In this article, we present a review of the literature concerning help‐seeking delays in lung cancer presentation, and more specifically, the role and influence that social factors may play in determining when and how people decide to seek medical help. We also consider how these factors contribute to patients’ understanding of symptoms and illness indicators. We suggest that while there is research highlighting the importance of psychosocial influences on the general help‐seeking behaviour of people with concerns about cancer, existing studies are mainly retrospective, and very little work has focused on identifying triggers and barriers specific to lung cancer. Further, we propose that while there have been a number of recent initiatives to raise awareness of the early signs of lung cancer, aimed at both patients and health professionals, little information provision has been targeted specifically at the formal and informal network level. This may be a useful avenue to pursue in future initiatives.     

Characteristics and medical-care-seeking of head and neck cancer patients: A population-based cross-sectional survey

ObjectivesWell-known risk factors, such as smoking and alcohol consumption, easily denounce head and neck cancer patients as smokers, alcohol abusers, and persons who are socially excluded and have low socioeconomic status. To diagnose these patients as early as possible, we should not have a prejudiced assumption of their characteristics.Materials and methodsWe collected detailed data on patient characteristics and health behavior and explored whether these traits had any effect on seeking medical advice in a population-based cross-sectional study involving 85 patients with head and neck cancer diagnosed between January 2003 and December 2007, residing in two health care districts (population 1,600,000) in Finland. The data were gathered from patient charts and questionnaires. The questionnaire data were compared with the general population in Finland.ResultsWe found these patients to be ordinary elderly people whose demographic and social features resembled those of the general population. They smoked more often, but otherwise had a rather healthy lifestyle. Only half were aware that smoking and alcohol consumption were risk factors of head and neck cancer. In a multivariate analysis, fear of physicians (adjusted odds ratio 11.0; 95% confidence interval 1.2–103), medical-care-seeking for symptoms other than pain (18.5; 2.2–156), and not suspecting cancer (11.2; 1.7–75.1) were independent risk factors for delayed consultation (combined appraisal and help-seeking interval over 3 months).ConclusionHead and neck cancer patients deviated from the same-aged general population only in excessive smoking. Fear of doctors, having no pain, and no suspicion of cancer resulted in delayed medical-care-seeking.     

The Symptom Burden in Breast Cancer Survivors

Breast cancer survivors continue to experience an array of physical, psychological and cognitive symptoms following the completion of their treatment. However, there is a lack of understanding of symptom burden during an extended and long-term survivorship. The present review attempts to provide an overview of conceptual and contextual understanding of symptom burden that women with breast cancer may experience following treatment completion. We will focus on six commonly reported symptoms or symptom clusters in post-treatment breast cancer survivors, including menopausal symptoms, lymphoedema, fatigue, depression, sleep disturbance and cognitive dysfunction. To identify and manage the symptom burden effectively, further investigation is required into individual symptoms and their relationship to others.     

Prospective predictors of psychosocial support service use after cancer

Objective: To identify prospective predictors of psychosocial support service utilisation by people with cancer. Consistent with the theory of planned behaviour (TPB), attitudes towards help seeking and behavioural intentions were predicted to lead to greater support service utilisation. Methods: A heterogeneous sample of cancer patients from a regional cancer treatment centre in Australia completed a prospective survey (n=439 at recruitment, 61.2% response rate; n=396 at follow‐up) examining the utilisation of psychosocial support services. Demographic variables (age and gender), social support, social constraints, cancer specific distress, and positive and negative attitudes towards help seeking were examined as prospective predictors of support service use. Further, a series of regression analyses explored mediation of the relationship between attitudes to seeking help and support service use by behavioural intentions. Results: Approximately 14% of cancer patients reported using a psychosocial support service in the 6 months following the time of the first study. Females and patients with more positive attitudes towards help seeking were more likely to have utilised a support service in the 6 months following recruitment. The relationship between positive attitudes to seeking help and psychosocial support service use was mediated by behavioural intentions. Conclusions: The TPB appears to have utility in explaining in part use of psychosocial help services. Future studies should include contextual factors in the model. Copyright © 2010 John Wiley & Sons, Ltd.     

Contextual and stress process factors associated with head and neck cancer caregivers’ physical and psychological well‐being

Head and neck cancer (HNC) caregivers are especially vulnerable to poor outcomes because the HNC patients are at high risk for physical and functional impairments. This study examines contextual and stress process variables potentially associated with HNC caregivers’ physical and psychological well‐being. Patient‐caregiver variables included socio‐demographics, primary stressors (caregiving, patient clinical characteristics, HNC‐related symptoms/dysfunction), secondary stressors (caregiver employment, childcare responsibilities and sleep duration <7 hr), appraisal, and response (physical activity). General linear models modeled caregiver well‐being, along with depression and anxiety. A total of 33 patient‐caregiver dyads were included. Most caregivers were female (81.8%) and patient spouses/partners (72.7%). Factors significantly associated with better caregiver physical well‐being included caregiver older age, <2 comorbidities, ≥7 hr of sleep, ≥3 days/week physical activity, and patient swallowing and speech dysfunction. Factors significantly associated with better caregiver mental health functioning were less patient social dysfunction and less perceived caregiving burden. Short nighttime sleep, higher caregiver burden, and <3 days/week physical activity were also significantly related to caregivers’ depression and anxiety. Results suggested caregiver behaviors and perceived burden, along with patient HNC concerns are linked with caregiver well‐being. These behavioral, cognitive, and patient factors should be incorporated into caregiver screening tools or targeted with behavioral interventions to improve caregiver well‐being.     

Time from Self-Detection of Symptoms to Seeking Definitive Care among Cervical Cancer Patients

Background: India had the burden of 97,000 new cases of cervical cancer with 60,000 deaths accounting nearly one-third of global cervical cancer deaths during the year 2018. Cervical cancer is the leading cause of cancer mortality in India. The present study aims to estimate the time interval between self-detection of cervical cancer symptoms and seeking care and different barriers for the possible time lag in seeking care. Methods: A cross-sectional study was undertaken from April 2017 to September 2017 in a regional cancer centre in the south of India. The centre has both a population and a hospital-based cancer registry. Cervical cancer cases (N= 210) with histological confirmation were interviewed at the hospital using a pre-tested semi-structured questionnaire. Results: The median time interval between the self-detection of cervical cancer symptoms and first contact with the general physician was 80 [IQR 45-150] days. The overall median time interval between the self-detection of symptoms to the initiation of primary treatment was 123[IQR 83-205] days. The major perceived reason for not seeking medical care was a lack of awareness in identifying cervical cancer symptoms in 183(92.9%) women. Conclusion: The median time of 80 days was observed from the self-detection of cervical cancer symptoms to the first contact with a general physician. Lack of awareness of patients pertaining to cancer symptoms was the major concern in seeking cancer care.     

Help‐seeking experiences of men diagnosed with colorectal cancer: a qualitative study

Advanced‐stage diagnosis of colorectal cancer (CRC) leads to poor prognosis and reduced survival rates. The current study seeks to explore the reasons for diagnostic delays in a sample of Australian men with CRC. Semi‐structured interviews were conducted in a purposive sample of 20 male CRC patients. Data collection ceased when no new data emerged. Interviews were audiotaped, transcribed and thematically analysed using Andersen's Model of Total Patient Delay as the theoretical framework. Most participants (18/20) had experienced lower bowel symptoms prior to diagnosis. Patient‐related delays were more common than delays attributable to the health‐care system. Data regarding patient delays fit within the first four stages of Andersen's model. The barriers to seeking timely medical advice were mainly attributed to misinterpretation of symptoms, fear of cancer diagnosis, reticence to discuss the symptoms or consulting a general practitioner. Treatment delays were a minor cause for delayed diagnosis. Delay in referral and scheduling for colonoscopy were among the system‐delay factors. In many instances, delays resulted from men's failure to attribute their symptoms to cancer and, subsequently, delay in diagnosis.