Factors Contributing to Delays in the Management of Lung Cancer: Retrospective Study From Government Cancer Center in India

Abstract

Background: Lung cancer is one of the leading causes of cancer related morbidity and mortality among both the sexes. It accounts for 13% of all new cancer cases and 19% of cancer related deaths worldwide. In India, lung cancer constitutes 6.9% of all new cancer cases and 9.3% of all cancer related deaths in both sexes. Majority of them present in advanced disease. Aim: This study aims to identify the contributing factors for delays in lung cancer diagnosis and treatment. Methods: This is a retrospective cross-sectional observational study which was conducted at Department of Oncology, Mysore Medical College and Research Institute, India. Records of the all histologically confirmed lung cancer patients from the year 2011 to 2016 were reviewed. Results: A total of 133 patients were identified with lung cancer and their records were evaluated. Out of these 133 patients, 60% of the cases were males. The median age was 63 years with the youngest being 37 and the eldest was 83 years. Majority of patients were in stage III (59%) and IV (36%). About 89% of the patients were smokers. Non–small cell lung cancer accounted 83% (squamous cell 66.5%, adenocarcinoma 30.5%, large cell 1.5% and neuroendocrine 1.5%) and small cell lung cancer was 17%. A total of 17% (26) of patient were on empirical antitubercular treatment (ATT) since the onset of current symptoms. While analyzing delay with independent T test showed mean delay of 25.01 days (± SD 6.17) in patient without ATT and with ATT delay was 57.09 days (± SD 8.05) ( P ≤ 0.01). Thirty five percentage (46) of patient received treatment within 1 month from the first hospital visit, 28% (37) within two months and 37% (50) within 3-4 months of the first hospital visit. The delay to hospital visit was shorter in advanced cancer and small cell cancer maybe because of the acute presenting symptoms. Conclusion: Various factors contributing for the delays are lag time from symptom onset to first visit with primary physician, delay due to investigation and symptomatic treatment under primary physician care, delay further aggravated by empirical but inappropriate ATT, further delay due to diagnostic procedure to establish the cancer diagnosis. Thus proper and timely referral to the specialist from primary physician will reduce these delays and help to avoid situation where curable disease become incurable and significantly alters the prognosis.

Navigating patient journey in early diagnosis of lung cancer in India

“…In India, the high endemicity of tuberculosis (TB) and the overlap of its symptomatology and radiological features with LC have created a scenario where a significant number of patients (up to 42.5%) have been misdiagnosed with TB, due to a low index of suspicion toward LC. [ 4 , 8 , 31 – 35 ] Anti-TB treatment is empirically commenced for sputum-acid-fast bacillus–negative patients with lung shadows that do not resolve with antibiotic treatment. [ 31 , 32 ] This could lead to a substantial delay in diagnosis of LC, which in turn may lead to stage progression and higher mortality[ 4 , 8 , 9 , 31 – 35 ] [ Table 1 ].…”

“…[ 4 , 8 , 31 – 35 ] Anti-TB treatment is empirically commenced for sputum-acid-fast bacillus–negative patients with lung shadows that do not resolve with antibiotic treatment. [ 31 , 32 ] This could lead to a substantial delay in diagnosis of LC, which in turn may lead to stage progression and higher mortality[ 4 , 8 , 9 , 31 – 35 ] [ Table 1 ].…”

“…Other challenges at the primary care level may include lag time from symptom onset to the first visit to the PCP, delay due to investigation and symptomatic treatment, and the diagnostic procedure to establish the cancer diagnosis apart from the non-availability of advanced diagnostic procedures and specialists. [ 31 ] Low awareness of LC symptoms,[ 13 ] financial constraints and inadequate or inaccessible healthcare facilities are some of the factors shown to modify the healthcare-seeking behaviour at the grass-roots level. [ 8 , 35 ]…”

“…Early diagnosis of LC relies mainly on prompt patient presentation and timely referral of patients with symptoms suggestive of LC by GPs to a specialist. [ 8 , 31 ]…”