The Experience in Nicaragua: Childhood Leukemia in Low Income Countries—The Main Cause of Late Diagnosis May Be “Medical Delay”

Abstract

Background. The event-free survival for pediatric leukemia in low-income Countries is much lower than in high-income countries. Late diagnosis, which is regarded as a contributing factor, may be due to “parental” or “medical” delay. Procedures. The present study analyses determinants of lag time from first symptoms to diagnosis of leukemia, comparing pediatric (0–16 years old) patients in two referral centers, one in Nicaragua and one in Italy. An observational retrospective study was conducted to assess factors influencing the time to diagnosis. Results. 81 charts of children diagnosed with acute myeloid leukemia or lymphoblastic leukemia were analyzed from each centre. Median lag time to diagnosis was higher in Nicaragua than in Italy (29 versus 14 days, P < 0.001) and it was mainly due to “physician delay” (16.5 versus 7 days, P < 0.001), whereas “patient delay” from symptoms to first medical assessment was similar in the two centers (7 versus 5 days, P = 0.27). Moreover, median lag time from symptoms to diagnosis was decreased in Nicaraguan districts were a specific training program upon childhood oncological diseases was carried out (20.5 versus 40 days, P = 0.0019). Conclusions. Our study shows that delay in diagnosis of childhood leukemia is mainly associated with “physician delay” and it may be overcome by programs of continuous medical education.

Factors influencing time to diagnosis and initiation of treatment of endemic Burkitt Lymphoma among children in Uganda and western Kenya: a cross-sectional survey

“…In contrast, guardian delay in the present study was considerably longer than previous reports—9 weeks in Kenya and 4.6 weeks in Uganda as compared to 1 to 2 weeks in other LMIC settings studied [11,13,14]. Overall, our findings differ from those previously reported, which have shown a tendency for guardian delay to be less than health system delay, both in LMIC and HIC [11,13,14,16]. …”

“…Median health system delay was 2 weeks in Kenya and 2.6 weeks in Uganda, Length of health system delay at both sites was comparable to data from earlier studies on delays for other childhood cancers in LMIC: in Nicaragua (2 weeks) and South Africa (3 weeks), although less than delays observed in Nigeria (9 weeks) [11,13,14]. In contrast, guardian delay in the present study was considerably longer than previous reports—9 weeks in Kenya and 4.6 weeks in Uganda as compared to 1 to 2 weeks in other LMIC settings studied [11,13,14]. Overall, our findings differ from those previously reported, which have shown a tendency for guardian delay to be less than health system delay, both in LMIC and HIC [11,13,14,16].…”

Delays in diagnosis and treatment of childhood cancer in Indonesia

“…Our median diagnosis delay (58 days) was significantly longer than median treatment delay (3 days). This median diagnosis delay is longer compared to study findings from high‐income countries, such as Italy (14 days), and also longer compared to African countries such as South Africa (38 days), Nigeria (29 days), and Egypt (28 days) . Establishing the diagnosis of cancer may need sophisticated and expensive examinations.…”

“…In addition, HCP's lack of knowledge and ability to recognize cancer‐related symptoms contribute to prolonged physician delays. In this regard, an interesting study found that median diagnosis delay among children with leukemia was significantly longer in Nicaragua (low‐income country) versus Italy (high‐income country). This was mainly due to “physician delay,” whereas “patient delay” was similar in both centers.…”

“…By definition, six types of delay were distinguished (Fig. ) . Parents were inquired when the symptoms started and on which date they visited the first health facility.…”