Barriers to Obtaining a Timely Diagnosis in Human Papillomavirus–Associated Oropharynx Cancer

Abstract

Objective Failure to recognize symptoms of human papillomavirus–associated oropharyngeal squamous cell carcinoma (HPV(+)OPSCC) at presentation can delay diagnosis and treatment. This study aims to identify patient factors and provider patterns that contribute to delayed diagnosis. Study Design Retrospective case series. Setting Tertiary care center. Methods Patients with HPV(+)OPSCC receiving intent-to-cure treatment from 2006 to 2016. Clinical data, workup, and care timelines were abstracted. Univariate and multivariable linear regressions were performed to determine associations. Results Of 703 included patients, 627 (89%) were male, and mean (SD) age at diagnosis was 59 (9) years. The mean (SD) delay to diagnosis was 148.8 (243.51) days, with an average delay of 63 (154.91) days from symptom onset to first presentation and 82.8 (194.25) days from first presentation to diagnosis. Most patients visited at least 2 providers (n = 546, 78%) before diagnosis and saw their primary care physician at first presentation (n = 496, 71%). The most common imaging and biopsy obtained before diagnosis was neck computed tomography (n = 391, 56%) and neck fine-needle aspiration (n = 423, 60%), respectively. On multivariable linear regression, being a homemaker, being a current smoker, seeing 3 or more providers, and getting a magnetic resonance imaging scan were associated with significant delays in diagnosis ( P < .01, all). Treatment with antibiotics and a suspicion for HPV(+)OPSCC at first presentation were associated with decreased delays in diagnosis ( P < .01, both). Conclusions Patient delays in seeking medical attention and provider delays in recognizing the appropriate diagnosis both contribute to delays of care in HPV(+)OPSCC. Improved patient and provider education is necessary to expedite the diagnosis of HPV(+)OPSCC.

Evaluation of Patient‐Reported Delays and Affordability‐Related Barriers to Care in Head and Neck Cancer

“…24,25 In a study assessing delays in diagnosis of HPV-positive oropharyngeal cancer, Karp et al noted that retired patients had a trend toward quicker diagnosis ( P = .05). 26 Retired individuals may have more time and savings to address important health issues, which may explain our finding that younger age was associated with barriers to care. Finally, female sex was associated with patient-reported barriers to care in our model but did not reach statistical significance in the stratified analyses.…”

Ultrasound Guided Biopsy in Patients With HPV‐Associated Oropharyngeal Squamous Cell Carcinoma

“…Though previous studies have compared ultrasound and palpation guided FNA accuracy in head and neck masses, this is the first to compare these techniques solely in patients with HPV(+)OPSCC. Our results have direct implications on clinical practice and the optimal diagnostic pathway for this disease, which often poses a challenge for primary care providers and otolaryngologists alike 2,19 …”

“…Although delays in diagnosis may not directly affect oncologic outcomes in HPV(+)OPSCC, patients who require multiple diagnostic tests to reach a diagnosis may suffer increased illness anxiety, discomfort related to the procedure, and financial morbidity from additional tests or consultations required to achieve a diagnosis. In addition, a false negative biopsy may give patients and providers a false sense of security 2,21 . An argument for observation or repeat antibiotic trials could be made for an asymptomatic, historically low risk patient with no evidence of a primary tumor on imaging or physical exam and a negative or indeterminate FNA biopsy.…”

“…Human papillomavirus‐associated oropharyngeal squamous cell carcinoma (HPV(+)OPSCC) accounts for the majority of oropharynx cancer in the United States 1 . Early diagnosis of HPV(+)OPSCC can be difficult to attain due to its unique set of risk factors, patient demographics, and presenting symptoms when compared to non‐HPV associated head and neck cancer 2–4 . The most common presenting symptom in patients with this disease is a persistent, unilateral neck mass, 3 which is often the primary target for diagnostic biopsy.…”

“…1 Early diagnosis of HPV(+)OPSCC can be difficult to attain due to its unique set of risk factors, patient demographics, and presenting symptoms when compared to non-HPV associated head and neck cancer. [2][3][4] The most common presenting symptom in patients with this disease is a persistent, unilateral neck mass, 3 which is often the primary target for diagnostic biopsy. A cervical lymph node biopsy is among the most common methods for diagnosing HPV(+)OPSCC, 3,5 but the cystic nature of these nodes (Fig.…”