Delay in referral of oropharyngeal squamous cell carcinoma to secondary care correlates with a more advanced stage at presentation, and is associated with poorer survival

Abstract

Squamous carcinoma of the oropharynx presents with symptoms common to many benign diseases, and this can cause delay in referral to secondary care. We investigate delay in referral, defining this as the time from symptom-onset to date of general practitioners referral letter to secondary care, and the effect of that delay, using a retrospective case notes based study of patients presenting at our institution with oropharyngeal squamous carcinoma between 1995 and 2005. Using correlation analysis and ordinal regression, we examined the relationship between increased referral delay from primary care, clinical stage at presentation, and survival. Increasing time from symptom onset to referral to secondary care was positively correlated with more advanced disease stage at presentation (r s ¼ þ 0.346, P ¼ 0.004). This was confirmed with ordinal regression modelling (delay estimate ¼ 0.045, P ¼ 0.042). Patients with delay of less than 6 weeks had significantly improved survival compared to those with a delay of greater than 6 weeks (P ¼ 0.032). For every 1 week of delay in referral, we estimate that the stage of presentation will progress by 0.045 of 'a stage'.

Diagnostic delay and disease stage in head and neck cancer: A systematic review

“…An interesting and recurrent finding in five of the studies reviewed was that delay predicted survival, 13,24,31,33,35 which could be manifesting through a significant decrease in the probability of local control of the disease per month of delay. 4 Treatment delay has been causally associated with poorer disease control, 45 and it is likely that postsymptomatic diagnostic delay has the same effect.…”

Surgical Management of Oropharyngeal Squamous Cell Carcinoma

“…In a study by Pitchers et al [15], the most common presenting symptoms for OPSCC were a neck mass (49.3 %), sore throat (33.3 %), lesion seen by the patient (5.9 %), incidental finding by a physician (2.9 %), referred otalgia (2.9 %), dysphagia (2.9 %) and globus pharyngeus (1.4 %). When taking a history, it is also important to ask about hemoptysis, weight loss, trismus, limited tongue mobility and odynophagia [16].…”

Autoantibody Approach for Serum-Based Detection of Head and Neck Cancer

“…Early detection can also be improved by reducing diagnostic delays, reported to be between 3 (9, 10) and 6 months (11), in the primary care setting. It is estimated that, for every 1 week of delay, the stage of presentation will progress by 0.045 of a stage (12). Thus, a delay of several months may prove detrimental by decreasing a patient's chance of survival from 80% to 40%.…”

“…Thus, a delay of several months may prove detrimental by decreasing a patient's chance of survival from 80% to 40%. Misdiagnosis at initial presentation to primary care physicians is common and may be due to the nonspecific nature of presenting symptoms, technical difficulty of examination in the head and neck region, as well as the rarity of this type of cancer (12). In one large prospective study involving patients who presented with hoarseness to 11 general practices, the performance of primary physicians on cancer diagnosis was poor with sensitivity of 46% and specificity of 24% (13).…”