Diagnostic delays in head and neck cancers

Impact of Diagnostic and Treatment Delays on Survival and Treatment-Related Toxicities in Portuguese Patients With Head and Neck Cancer

INTRODUCTION

Delays in diagnosis and initiation of treatment have a negative impact on the prognosis and survival of head and neck cancer (HNC) patients. These delays also involve more intensive treatments with greater toxicity, dysfunction, and morbidity.

METHODS

This was a retrospective observational study with patients diagnosed with HNC between January 1, 2018, and December 31, 2021. The main objective was to estimate whether the time to diagnosis (TD) and time until treatment initiation (TIT) translated into changes in the patient's overall survival (OS). Multivariate data analysis was performed with the Cox regression model. Significance was considered for p<0.05.

RESULTS

A total of 139 patients were included in this study. Median TD was 126 days and median TIT was 43 days. No association between TD, TIT, treatment toxicity, and OS was found. Being a smoker was associated with a longer TD (p=0.05, hazard ratios {HR}=1.01). TIT was significantly shorter in higher grades (p=0.03, HR=0.57) and during coronavirus disease 2019 (COVID-19) (p=0.04, HR=0.57), but higher in larger disease (tumor {T}) (p=0.04, HR=1.39). A higher T (p=0.01, HR=2.67) and lymph node metastasis (nodes {N}) (p=0.02, HR=2.24) were identified as risk factors with a negative impact on OS, whereas grade was positively correlated (p=0.05, HR=0.32).

CONCLUSIONS

Even though there was no correlation between TD and TIT, and OS, action still needs to be taken to shorten these times. T and N remain negative predictive prognostic markers of HNC.

Current appraises of therapeutic applications of nanocurcumin: A novel drug delivery approach for biomaterials in dentistry

Curcumin is a natural herb and polyphenol that is obtained from the medicinal plant Curcuma longa. It's anti-bacterial, anti-inflammatory, anti-cancer, anti-mutagenic, antioxidant and antifungal properties can be leveraged to treat a myriad of oral and systemic diseases. However, natural curcumin has weak solubility, limited bioavailability and undergoes rapid degradation, which severely limits its therapeutic potential. To overcome these drawbacks, nanocurcumin (nCur) formulations have been developed for improved biomaterial delivery and enhanced treatment outcomes. This novel biomaterial holds tremendous promise for the treatment of various oral diseases, the majority of which are caused by dental biofilm. These include dental caries, periodontal disease, root canal infection and peri-implant diseases, as well as other non-biofilm mediated oral diseases such as oral cancer and oral lichen planus. A number of in-vitro studies have demonstrated the antibacterial efficacy of nCur in various formulations against common oral pathogens such as S. mutans, P. gingivalis and E. faecalis, which are strongly associated with dental caries, periodontitis and root canal infection, respectively. In addition, some clinical studies were suggestive of the notion that nCur can indeed enhance the clinical outcomes of oral diseases such as periodontitis and oral lichen planus, but the level of evidence was very low due to the small number of studies and the methodological limitations of the available studies. The versatility of nCur to treat a diverse range of oral diseases augurs well for its future in dentistry, as reflected by rapid pace in which studies pertaining to this topic are published in the scientific literature. In order to keep abreast of the latest development of nCur in dentistry, this narrative review was undertaken. The aim of this narrative review is to provide a contemporaneous update of the chemistry, properties, mechanism of action, and scientific evidence behind the usage of nCur in dentistry.

Patient delay and its clinical significance among head and neck cancer patients in Hungary

Introduction: Head and neck cancers represent a major health problem in Hungary. With their high incidence and mortality rates, Hungary is one of the world leaders in these indicators. The length of patient delay, defined as time from onset of symptoms to first medical consultation, is unknown in Hungarian patients with head and neck cancer. We aimed to use a representative sample of the Hungarian head and neck cancer patient population to determine patient delay according to disease localization and stage and to identify correlations with other clinical parameters. Methods: In our retrospective study, we reviewed patient documentation. For the inclusion, the patients had to be diagnosed with malignant tumors of the oral cavity, oropharynx, hypopharynx or larynx at the Department Head and Neck Surgery of Semmelweis University between 2012 and 2017. Results: We identified 236 patients who met the inclusion criteria. The median delay was 9.5 weeks (range 0-209 weeks) and the mean delay of patients was 17.57 weeks (SD 23.67). There was a significant difference in patient delay data by location. Among glottic cancers, the most common diagnosis was an early stage (67%), compared with other localizations, including most commonly the oropharynx (81%) and hypopharynx (80%), where a locoregionally advanced stage was more frequent. Discussion: Compared to data from different countries, the delay of Hungarian patients with head and neck cancer is significantly longer, which may contribute to the high mortality in Hungary. Screening and patient education in high-risk groups could contribute to earlier diagnosis and thus improve prognosis.

Evaluating the reasons for delays in treatment of oral cavity cancer patients

The growing increase in oral cavity cancer (OSCC) incidence constitutes a severe diagnostic-therapeutic problem – and early diagnosis, as well as medical treatment remain important priorities of maxillofacial oncology. The aim of this paper was to determine the reasons for delays in the diagnostics and treatment of oral cavity cancer patients. The study focused on 248 patients (=56.1 years) post-surgery, in which delays in diagnostics and treatment were reported. As for the causes, most frequently, in 171 cases (69.0%), patient delays were reported, in 56 cases, physician delays were observed, and in 21 cases (8.5%), organizational reasons were to blame. The median time period between the onset of the symptoms and seeking medical attention was 143 days. Time interval between the first contact with a doctor and commencement of oncological treatment was 33.2 days approximately. The majority of the patients were not aware of the oral cavity cancer risk. Misdiagnosis of symptoms as inflammation, as well as prolonged antibiotic therapy and diagnostics constitute main reasons for physician and organization-al/health care system delays. Raising patients’ awareness of cancer risk, as well as educational and promotional programs for physicians are the principal goals of a strategy aiming to enhance oral cancer diagnosis.

Factors associated with diagnosis delay in head and neck cancer

INTRODUCTION AND OBJECTIVES

Tumour stage is an important prognostic factor in head and neck tumours. Many tumours are diagnosed in advanced stages despite almost universal healthcare and their being symptomatic. This paper seeks to determine the diagnostic delay in head and neck tumours in our health department, to analyse factors associated with delay and if it is associated with diagnosis in advanced stages.

METHODS

Retrospective study of 137 patients with head and neck cancer diagnosed from 2016-2018. Patient delay, delay in primary health care, delay in secondary health care, diagnostic delay and possible associated factors (smoking, location, stage, …) were evaluated.

RESULTS

Many patients (44.5%) were diagnosed in advanced stages. The median patient delay was 30 days. The median referral to otorhinolaryngology was 3.5 days. If the referral was made by another specialist (p = .008), the patients were under previous treatment (P=.000) and the tumours were in initial stages (P=.038) this delay was greater. The median from the first visit to otorhinolaryngology was 15 days, higher in regular referrals (43%) (P=.000). The median diagnostic delay was 12 days, higher in surgical biopsies (P=.000). The median professional delay was 58.5 days and total delay was 118.5 days.

CONCLUSIONS

Many head and neck tumours are diagnosed in advanced stages. A relationship was not found between diagnosis in advanced stages and diagnostic delay. However, steps must be taken to reduce these excessive delays.

Factors associated with diagnosis delay in head and neck cancer

INTRODUCTION AND OBJECTIVES

Tumour stage is an important prognostic factor in head and neck tumours. Many tumours are diagnosed in advanced stages despite almost universal healthcare and their being symptomatic. This paper seeks to determine the diagnostic delay in head and neck tumours in our health department, to analyse factors associated with delay and if it is associated with diagnosis in advanced stages.

METHODS

Retrospective study of 137 patients with head and neck cancer diagnosed from 2016-2018. Patient delay, delay in primary health care, delay in secondary health care, diagnostic delay and possible associated factors (smoking, location, stage, …) were evaluated.

RESULTS

Many patients (44.5%) were diagnosed in advanced stages. The median patient delay was 30 days. The median referral to otorhinolaryngology was 3.5 days. If the referral was made by another specialist (p=.008), the patients were under previous treatment (P=.000) and the tumours were in initial stages (P=.038) this delay was greater. The median from the first visit to otorhinolaryngology was 15 days, higher in regular referrals (43%) (P=.000). The median diagnostic delay was 12 days, higher in surgical biopsies (P=.000). The median professional delay was 58.5 days and total delay was 118.5 days.

CONCLUSIONS

Many head and neck tumours are diagnosed in advanced stages. A relationship was not found between diagnosis in advanced stages and diagnostic delay. However, steps must be taken to reduce these excessive delays.

Determinants of delay in the head and neck oncology care pathway: The next step in value-based health care

Objective

Head and neck squamous cell carcinomas (HNSCC) are relatively fast‐growing tumours, and delay of treatment is associated with tumour progression and adverse outcomes. The aim of this study is to identify determinants of delay in a head and neck oncology centre.

Methods

This cohort study with prospectively collected data investigated associations between patient (including geriatric assessment at first consultation), tumour and treatment characteristics and treatment delay. Two quality indicator intervals assessing value‐based healthcare were studied: care pathway interval (CPI, interval between first visit in an HNOC and treatment initiation) and time‐to‐treatment initiation (TTI, interval between histopathological confirmation of HNSCC and treatment initiation), using regression analyses.

Results

Stage‐IV tumours and initial radiotherapy were independent predictors of delay in CPI. Initial radiotherapy was associated with delay in TTI. Overall, 37% of the patients started treatment within 30 days after first consultation (67% in case of initial surgical treatment and 11.5% if treated with (chemo)radiation, p < 0.001). Geriatric assessment outcomes were not associated with delay. Indicators for delay in initial surgery patients were stage‐IV tumours (CPI).

Conclusion

The majority of HNSCC patients encounter delay in treatment initiation, specifically in patients with advanced‐stage tumours or when radiotherapy is indicated.

Delay in diagnosis of patients with head-and-neck cancer in Canada: impact of patient and provider delay

Background

Head-and-neck cancers (hncs) often present at an advanced stage, leading to poor outcomes. Late presentation might be attributable to patient delays (reluctance to seek treatment, for instance) or provider delays (misdiagnosis, prolonged wait time for consultation, for example). The objective of the present study was to examine the length and cause of such delays in a Canadian universal health care setting.

Methods

Patients presenting for the first time to the hnc multidisciplinary team (mdt) with a biopsy-proven hnc were recruited to this study. Patients completed a survey querying initial symptom presentation, their previous medical appointments, and length of time between appointments. Clinical and demographic data were collected for all patients.

Results

The average time for patients to have their first appointment at the mdt clinic was 15.1 months, consisting of 3.9 months for patients to see a health care provider (hcp) for the first time since symptom onset and 10.7 months from first hcp appointment to the mdt clinic. Patients saw an average of 3 hcps before the mdt clinic visit (range: 1-7). No significant differences in time to presentation were found based on stage at presentation or anatomic site.

Conclusions

At our tertiary care cancer centre, a patient's clinical pathway to being seen at the mdt clinic shows significant delays, particularly in the time from the first hcp visit to mdt referral. Possible methods to mitigate delay include education about hnc for patients and providers alike, and a more streamlined referral system.

Factors influencing patient and health care delays in Oropharyngeal Cancer

BACKGROUND

The incidence of human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC) is increasing. Patients with HPV-associated and HPV-unassociated OPSCC differ in many aspects, which may also impact their diagnostic and management timelines. This study aims at studying the patient, primary health care (PHC) and specialist-care (SC) delays and possible differences between these two patient groups in seeking medical care.

METHODS

We reviewed all new patients with OPSCC treated between 2016 and 2018 at our institute, which covers a referral area of 1.6 million people. We collected data on patients' symptoms and factors influencing why they sought medical care using a patient-reported questionnaire and hospital records. We compared delays based on patient and tumor characteristics.

RESULTS

In our study population of 83 patients, the median patient delay was 30 days (range, 0-366), with a median PHC delay of 15 days (range, 0 days-2.5 years), and a median SC delay of 54 days (range, 12-231). The SC delay was further divided into diagnostic hospital delay and treatment delay, each with a median length of 16 days (range, 0-237) and 29 days (range, 0-73), respectively. Furthermore, we found that p16 status did not associate with delays. A longer patient delay associated with specific tumor factors, such as a larger primary tumor and a lower UICC 7th edition stage. Patients that had multiple visits or did not have a follow-up visit scheduled at the initial appointment had longer PHC delays. Treatment delay was significantly longer for patients scheduled for (chemo-)radiotherapy than for those undergoing surgery with or without (chemo-)radiotherapy.

CONCLUSIONS

Although delays remained short for the majority of OPSCC patients, long delays require further evaluation and improvement of management. Awareness of presenting symptoms among cancer risk patients and prompt referral practice or a follow-up visit at PHC represent key factors to shortening these delays. Ultimately, the causes for delays in SC appear multifactorial and require institutional quality control.

Impact of Time to Diagnosis and Treatment in Head and Neck Cancer: A Systematic Review

OBJECTIVE

An increased interval between symptomatic disease and treatment may negatively influence oncologic and/or functional outcomes in head and neck cancer (HNC). This systematic review aims to provide insight into the effects of time to treatment intervals on oncologic and functional outcomes in oral cavity, pharyngeal, and laryngeal cancer.

DATA SOURCES

PubMed, EMBASE, and Cochrane library were searched.

REVIEW METHODS

All studies on delay or time to diagnosis or treatment in oral, pharyngeal, and laryngeal cancer were included. Quality assessment was performed with an adjusted version of the Newcastle-Ottawa scale. Outcomes of interest were tumor volume, stage, recurrence, survival, patient-reported outcome measures (PROMs), toxicity, and functionality after treatment.

RESULTS

A total of 51 studies were included. Current literature on the influence of delay in HNC is inconsistent but indicates higher stage and worse survival with longer delay. The effects on PROMs, toxicity, and functional outcome after treatment have not been investigated. The inconsistencies in outcomes were most likely caused by factors such as heterogeneity in study design, differences in the definitions of delay, bias of results, and incomplete adjustment for confounding factors in the included studies.

CONCLUSION

Irrespective of the level of evidence, the unfavorable effects of delay on oncologic, functional, and psychosocial outcomes are undisputed. Timely treatment while maintaining high-quality diagnostic procedures and decision making reflects good clinical practice in our opinion. This review will pose practical and logistic challenges that will have to be overcome.

Causes for delay before specialist consultation in head and neck cancer

BACKGROUND

Head and neck cancers are often diagnosed at a late stage, thus resulting in a generally poor prognosis. This is partly attributable to patients' hesitancy in seeking treatment. However, the length and causes of these patient delays remain relatively unknown.

MATERIAL AND METHODS

We included all new head and neck cancer patients treated at our tertiary care center between 2016 and 2017. Using a patient questionnaire, we collected data on patients' symptoms and other factors related to seeking medical care, and recorded both patient- and primary health care-related delays. We then compared the data collected from these patients to patient and tumor characteristics collected from hospital records, and analyzed various causes for delay before a specialist consultation to the Department of Otorhinolaryngology - Head and Neck Surgery.

RESULTS

Among the patients (n = 142) in our study, the median patient delay was 35 d with 73% of patients seeking medical care within 3 months. In comparison, the median primary health-care delay was 20 d. Certain symptoms influenced patient delay. Hoarseness and breathing difficulties correlated with longer patient delay while patients with a lump on the neck had a shorter delay. Patient delay was associated with certain tumor-related factors such as the tumor site and the presence of regional metastases, which resulted in shorter patient delay. None of the patient-related factors appeared to impact delay. Important factors influencing primary health-care delay included the initial location visited and whether any follow-up visit was scheduled or not.

CONCLUSIONS

Although most patients sought medical advice without a major delay and were adequately referred, we found that long delays existed. Raising awareness of the symptoms of head and neck cancer among general population and health-care providers is probably the best way to get patients to curative treatment without delay.

Cognitive and emotional processes influencing patient presentation or non-presentation of oral Cancer symptoms to healthcare professionals

OBJECTIVE

Greater time that patients take to present symptoms to health care providers (HCPs) increases the likelihood of later stage cancer, which increases mortality and morbidity in symptomatic cancers. The common-sense model (CSM) is used to understand time to first consultation with a healthcare provider, but inconsistencies exisy between its current use and important empirical findings.

METHOD

To resolve inconsistencies, we conducted a qualitative examination to determine how the CSM could be revised to better account for these findings. We conducted in-depth interviews of a consecutive sample of 38 recently diagnosed patients who described events from first noticing symptoms to first consultation. Framework analysis was used to develop a theoretical model of processes leading to presentation or non-presentation.

RESULTS

Patients reported median presentation times of 3-4 weeks. Early presentation was facilitated by pre-symptomatic perceptions of vulnerability to serious illnesses and beliefs that early intervention could mitigate illness. These patients rarely tried to identify symptoms. They responded inductively, seeking help because symptoms were unusual. Where patients did not describe pre-symptom perceptions of vulnerability, many deductively tried to identify symptoms but misattributed them to minor conditions. Pre-symptomatic perceptions of vulnerability could also prolong presentation. When vulnerability was characterized by intense fears of cancer and cancer treatment, patients tended to avoid thinking about symptoms which extended presentation time.

CONCLUSION

Risk perception theories explain how participants' pre-symptomatic perceptions of vulnerability and potential treatment outcomes influence presentation time. Incorporating risk perception perspectives into the CSM can improve its ability explain responses to ambiguous symptoms.

An overview of application of silver nanoparticles for biomaterials in dentistry

Oral cavity is a gateway to the entire body and protection of this gateway is a major goal in dentistry. Plaque biofilm is a major cause of majority of dental diseases and although various biomaterials have been applied for their cure, limitations pertaining to the material properties prevent achievement of desired outcomes. Nanoparticle applications have become useful tools for various dental applications in endodontics, periodontics, restorative dentistry, orthodontics and oral cancers. Off these, silver nanoparticles (AgNPs) have been used in medicine and dentistry due to its antimicrobial properties. AgNPs have been incorporated into biomaterials in order to prevent or reduce biofilm formation. Due to greater surface to volume ratio and small particle size, they possess excellent antimicrobial action without affecting the mechanical properties of the material. This unique property of AgNPs makes these materials as fillers of choice in different biomaterials whereby they play a vital role in improving the properties. This review aims to discuss the influence of addition of AgNPs to various biomaterials used in different dental applications.

Silver nanoparticles in dentistry

OBJECTIVE

Silver nanoparticles (AgNPs) have been extensively studied for their antimicrobial properties, which provide an extensive applicability in dentistry. Because of this increasing interest in AgNPs, the objective of this paper was to review their use in nanocomposites; implant coatings; pre-formulation with antimicrobial activity against cariogenic pathogens, periodontal biofilm, fungal pathogens and endodontic bacteria; and other applications such as treatment of oral cancer and local anesthesia. Recent achievements in the study of the mechanism of action and the most important toxicological aspects are also presented.

METHODS

Systematic searches were carried out in Web of Science (ISI), Google, PubMed, SciFinder and EspaceNet databases with the keywords "silver nano* or AgNP*" and "dentist* or dental* or odontol*".

RESULTS

A total of 155 peer-reviewed articles were reviewed. Most of them were published in the period of 2012-2017, demonstrating that this topic currently represents an important trend in dentistry research. In vitro studies reveal the excellent antimicrobial activity of AgNPs when associated with dental materials such as nanocomposites, acrylic resins, resin co-monomers, adhesives, intracanal medication, and implant coatings. Moreover, AgNPs were demonstrated to be interesting tools in the treatment of oral cancers due to their antitumor properties.

SIGNIFICANCE

The literature indicates that AgNPs are a promising system with important features such as antimicrobial, anti-inflammatory and antitumor activity, and a potential carrier in sustained drug delivery. However, there are some aspects of the mechanisms of action of AgNPs, and some important toxicological aspects arising from the use of this system that must be completely elucidated.

Factors Associated with Delay in the Diagnosis of Oral Cancer

Early detection and treatment improve the prognosis for oral cancer. Delays from the onset of symptoms to clinical diagnosis are common. Our aim is to identify factors associated with this delay. Between 1995 and 1998, we interviewed 105 consecutive patients with histologically confirmed oral cancer in Greece. If 21 or more days elapsed from the time the patient noticed major symptoms to a definitive diagnosis, we called it a delay (52% of cases). We used logistic and linear regression to estimate odds ratios of delayed diagnosis and to identify correlates of length of delay, respectively. Former smokers had a 4.3 times greater risk of delayed diagnosis compared with current smokers (95% confidence interval: 1.1-17.1). The length of delay was greater among single patients, non-smokers, or those with stage IV tumors. Clinicians should be advised that delay in the diagnosis of oral cancer occurs frequently, even in individuals who do not smoke heavily.

Silver Nanoparticles Exhibit the Dose-Dependent Anti-Proliferative Effect against Human Squamous Carcinoma Cells Attenuated in the Presence of Berberine

The biological activity of nanosize silver particles towards oral epithelium-derived carcinoma seems to be still underinvestigated. We evaluated the influence of low doses of nanosize scale silver particles on the proliferation and viability of malignant oral epithelial keratinocytes in vitro, alone and in conjunction with the plant alkaloid berberine. Cells of human tongue squamous carcinoma SCC-25 (ATCC CRL-1628), cultivated with the mixture of Dulbecco's modified Eagle’s medium, were exposed to silver nanoparticles alone (AgNPs, concentrations from 0.31 to 10 μg/mL) and to a combination of AgNPs with berberine chloride (BER, 1/2 IC₅₀ concentration) during 24 h and 48 h. The cytotoxic activity of AgNPs with diameters of 10 nm ± 4 nm was measured by 3-(4,5-dimethyl-2-thiazyl)-2,5-diphenyl-2H-tetrazolium bromide (MTT) assay. Cell cycle analysis was performed by treating cells with propidium iodide followed by flow-activated cell sorting. RT-QPCR reaction was used to assess expression of anti-apoptotic proteins Bcl-2 and pro-apoptotic protein Bcl-2-associated X protein Bax genes expression. Monodisperse silver nanoparticles at a concentration of 10 μg/mL arrested SCC-25 cells cycle after 48 h at the G0/G1 phase in a dose- and time-dependent manner through disruption G0/G1 checkpoint, with increase of Bax/Bcl-2 ratio gene expression. AgNPs exhibit cytotoxic effects on SCC-25 malignant oral epithelial keratinocytes, which is diminished when combined with BER. The AgNPs concentration required to inhibit the growth of carcinoma cells by 50% (IC₅₀) after 48 h was estimated at 5.19 μg/mL. AgNPs combined with BER increased the expression of Bcl-2 while decreasing the ratio of Bax/Bcl-2 in SCC-25 cells. Silver particles at low doses therefore reduce the proliferation and viability of oral squamous cell carcinoma cells. SCC-25 cells are susceptible to damage from AgNPs-induced stress, which can be regulated by the natural alkaloid berberine, suggesting that nanoparticles may be potentially used in a chemoprevention/chemotherapy by augmentation of action of standard anti-cancer drugs.

Size-Dependent Nanoparticle Uptake by Endothelial Cells in a Capillary Flow System

An in vitro cell culture system is developed for studying the uptake characteristics of nanoparticles (NPs) by endothelial cells under shear stress. Results show that the smaller polystyrene nanospheres are uptaken more than larger nanospheres for sizes ranging from 100 nm to 500 nm for 12, 24, and 48 hrs delivery times. While the result is similar to that found in static cultures, the observed trend is different from NP delivery behaviors to a simple glass surface in a flow, where no clear size dependence was observed because of repulsive electrostatic force on marginating NPs. The trend is also opposite to the behavior found in another study of the adhesion of labeled particles onto endothelial cells in whole blood flow. The comparison shows that the reduced zeta potential of NPs in a serum-containing cell medium and particle removal by cells results in reduced repulsive electrostatic force on marginating NPs. Consequently, the uptake behaviors are dominated by Brownian diffusion and cell membrane deformation process, which favor the uptake of NPs with reduced sizes.

Identifying the Factors Causing Delayed Presentation of Cancer Patients to a Government Medical College of Central India

BACKGROUND

The incidence of cancer is increasing throughout the world. One of the prime aims of its management is early diagnosis and therapeutic intervention. Factors causing delay to either of these goals should be identified and rectified.

AIM

To identify the factors causing delayed initial diagnosis and subsequent management in patients presenting to the Oncology department.

MATERIALS AND METHODS

Three hundred proven cancer patients were prospectively evaluated for the pattern of presentation to the outpatient Department of Radiation Oncology of a Government Medical College (MC) in Central India.

RESULTS

The mean age of presentation was 51.05 years (range 7 months-77 years). The number of male patients was 168 while females were 132. The duration of symptoms ranged from 20 days to 3 years. The number of patients with little/no education presented mainly in advanced stages as compared to their educated counterpart and this difference was statistically significant (p<0.001). The number of patients presenting directly to the department was 108, those diagnosed outside and referred to us was 84 while those diagnosed and received some form of oncologic treatment outside and referred thereafter was 108. The difference in the primary delay between patients presenting directly to the MC versus those diagnosed outside was significant (p=0.0126). The mean duration of starting definitive treatment after presentation to the outpatient was 4.68 days (range 0-22 days) and was very significantly (p< 0.001) less than the secondary delays caused to the other two subsets of patients.

CONCLUSION

Factors causing delayed presentation are both patient and system related. It is imperative to educate the common people regarding the early signs and symptoms of cancer. At the same time, the system needs to overhaul its efficiency to avoid secondary delays that adversely affect the treatment outcome. An upgradation of the existing oncology facilities in the public sector can achieve this target efficiently.

Uptake and fate of surface modified silica nanoparticles in head and neck squamous cell carcinoma

Background

Head and neck squamous cell carcinoma (HNSCC) is currently the eighth leading cause of cancer death worldwide. The often severe side effects, functional impairments and unfavorable cosmetic outcome of conventional therapies for HNSCC have prompted the quest for novel treatment strategies, including the evaluation of nanotechnology to improve e.g. drug delivery and cancer imaging. Although silica nanoparticles hold great promise for biomedical applications, they have not yet been investigated in the context of HNSCC. In the present in-vitro study we thus analyzed the cytotoxicity, uptake and intracellular fate of 200-300 nm core-shell silica nanoparticles encapsulating fluorescent dye tris(bipyridine)ruthenium(II) dichloride with hydroxyl-, aminopropyl- or PEGylated surface modifications (Ru@SiO₂-OH, Ru@SiO₂-NH₂, Ru@SiO₂-PEG) in the human HNSCC cell line UMB-SCC 745.

Results

We found that at concentrations of 0.125 mg/ml, none of the nanoparticles used had a statistically significant effect on proliferation rates of UMB-SCC 745. Confocal and transmission electron microscopy showed an intracellular appearance of Ru@SiO₂-OH and Ru@SiO₂-NH₂ within 30 min. They were internalized both as single nanoparticles (presumably via clathrin-coated pits) or in clusters and always localized to cytoplasmic membrane-bounded vesicles. Immunocytochemical co-localization studies indicated that only a fraction of these nanoparticles were transferred to early endosomes, while the majority accumulated in large organelles. Ru@SiO₂-OH and Ru@SiO₂-NH₂ nanoparticles had never been observed to traffic to the lysosomal compartment and were rather propagated at cell division. Intracellular persistence of Ru@SiO₂-OH and Ru@SiO₂-NH₂ was thus traceable over 5 cell passages, but did not result in apparent changes in cell morphology and vitality. In contrast to Ru@SiO₂-OH and Ru@SiO₂-NH₂ uptake of Ru@SiO₂-PEG was minimal even after 24 h.

Conclusions

Our study is the first to provide evidence that silica-based nanoparticles may serve as useful tools for the development of novel treatment options in HNSCC. Their long intracellular persistence could be of advantage for e.g. chronic therapeutic modalities. However, their complex endocytotic pathways require further investigations.

Factors associated with late presentation of cancer: a limited literature review

According to the World Health Organization (WHO 2006), cancer is one of the leading causes of death worldwide. Deaths from cancer are projected to continue rising, with an estimated 9 million people dying from cancer in 2015 and 11.4 million dying in 2030 (WHO 2006). Delayed presentation or late diagnosis of cancer is associated with low survival. The aim of this review is to identify factors associated with delayed presentation of cancer that were reported by previous studies. Published studies which identified the most common factors attributed to the late presentation of cancer were reviewed. Publications were identified using MEDLINE (Medical Literature Analysis and Retrieval System Online), the Cochrane Library, CINAHL (Cumulative Index to Nursing and Allied Health Literature) and EMBASE (Excerpta Medica Database) databases. A Critical Appraisal Skills Programme (CASP) was used to assess the methodological quality of the studies. A total of 24 studies met the inclusion criteria. A data extraction sheet was used to systematically record relevant factors. Twenty-four studies met the inclusion criteria which identified factors associated with patients’ delay including patients’ knowledge, stress and fear, and nature of the disease. Other factors were attributed to health providers such as general practitioner (GP) experience, referral delay, and a younger age group being considered as low risk, so symptoms were missed.

Socio-economic factors and stage at presentation of head and neck cancer patients in Ottawa, Canada: a logistic regression analysis

To determine if socio-economic status (SES) affects the stage at presentation of head and neck cancer (HNC) patients in Ottawa, Canada. To determine if the method of diagnosis affects the stage at presentation in these patients. We obtained data on SES, method of diagnosis, and stage at presentation for patients presenting to the head and neck cancer clinic at The Ottawa Hospital Regional Cancer Centre (TORCC). We performed a logistic regression analysis using stage at presentation as the dependent variable. We found no statistically significant association between average family income (by postal code) and stage at presentation. We found that oral cancers presented at a later stage compared with other HNCs but that who made the diagnosis was an important factor. Oral cancers diagnosed by a dentist had 3.44 times the odds of being at a later stage than other HNCs (CI 1.01-11.96), but oral cancers diagnosed by other means had 11.42 times the odds of being at a later stage than other HNCs. We found that male patients presented at a later stage than female patients (OR 2.62, CI 1.03-6.63). Finally, former smokers had about 1/3 the odds of presenting at a later stage than current smokers (OR 0.33, CI 0.13-0.84) although nonsmokers were not significantly less likely than current smokers to present later (OR 0.47, CI 0.17-1.32). We found no evidence that in Ottawa, Canada patients of a lower SES with HNC presented at an different stage than patients with higher SES. We found that patients presenting with oral cancers presented at an earlier stage if they were diagnosed by a dentist.

Is early diagnosis of oral cancer a feasible objective? Who is to blame for diagnostic delay?

Worldwide, oral cancer has one of the lowest survival rates and poor prognosis remains unaffected despite recent therapeutic advances. Reducing diagnostic delay to achieve earlier detection is a cornerstone to improve survival. Thus, intervention strategies to minimize diagnostic delays resulting from patient factors and to identify groups at risk in different geographical areas seem to be necessary. The identification of a 'scheduling delay' in oral cancer justifies the introduction of additional educational interventions aimed at the whole health care team at dental and medical practices. The access to and the kind of healthcare system in a particular country are also relevant in this context, particularly the referral system. The design of a simple, clear, fail-safe, fast-track referral scheme for those suspected with cancer may diminish greatly the length of the delay. Moreover, there is a need for future investigations, which are methodologically adequate, that consider cultural and geographical aspects and use patient survival as the final outcome, that are able to recognize the agents/factors responsible for diagnostic delay by patients as well as healthcare providers and those attributable to the healthcare systems.

Changes from 1992 to 2002 in the pretreatment delay for patients with squamous cell carcinoma of larynx or pharynx: a Danish nationwide survey from DAHANCA

In Denmark, a general impression of prolonged pretreatment delay for patients with head and neck cancer led to a nationwide study of time spans from symptom debut over first health care contact to start of treatment. Charts of consecutive new patients with squamous cell carcinoma of the pharynx and larynx, seen at the five Danish oncology centers in January-April 1992 and 2002, respectively, were reviewed. Of the 288 patients identified, definitive treatment was radiotherapy in 264 cases, surgery in one case. Twenty-three patients had neither surgery nor radiotherapy. Total time from first health care contact to start of definitive treatment was significantly longer in 2002 than in 1992 (median 70 versus 50 days, p<0.001). There was no significantly difference in time used for diagnosis. Time for treatment preparation and planning was 46 days in 2002 versus 31 days in 1992 (p<0.001). Significantly more diagnostic procedures (CT, MR, US, PET) were done in 2002. In conclusion, this nationwide study showed that waiting time before start of radiotherapy was significantly longer in 2002 compared to 1992. An increasing number of imaging procedures including CT-based dose planning was observed. The prolongation was mainly related to shortage of radiotherapy capacity. The three weeks extra pretreatment delay could theoretically lead to a 10% lower tumor control probability in 2002 compared to 1992.

Help-seeking behaviour in patients with lymphoma

Reducing cancer mortality is a priority for the UK Government and emphasis has been placed on introducing targets to ensure prompt diagnosis. Help seeking is the first step on the pathway to diagnosis and should occur promptly; however, patients with lymphoma take longer to seek help for symptoms than those with many other cancers. Despite this, the help seeking behaviour of these patients has not been investigated. This qualitative study examined the beliefs and actions about help seeking among 32 patients, aged 65 and over and newly diagnosed with lymphoma in West Yorkshire during 2000. Patients reported an extremely wide range of symptoms which were not always interpreted as serious or potentially caused by cancer. This, in association with a clear lack of knowledge about lymphoma, often led to help seeking being deferred. The range and characteristics of symptoms can largely be explained in terms of variations in the type, site and size of the lymphoma. The UK Government targets focus on the time after help seeking, yet for lymphoma it is also crucial to reduce the time taken to seek help. More education about the potential symptoms of this disease is needed among the general public.

Diagnostic biopsy of lymph nodes of the neck, axilla and groin: rhyme, reason or chance?

INTRODUCTION

Improving patient pathways of care is becoming increasingly important in the delivery of timely, appropriate surgical care. With this aim, we analysed the referral and management pathway of patients undergoing diagnostic superficial lymph node biopsy.

PATIENTS AND METHODS

A retrospective review of case notes of patients undergoing diagnostic superficial lymph node biopsy over 3 years, 1998-2000 at the Bradford Hospitals NHS Trust. Indication for surgical biopsy was based on clinical suspicion following assessment in the out-patient clinic for the majority, and arrangement of investigations as deemed appropriate. There were no clinical algorithms in use during the study period.

RESULTS

There was no evidence for the use of explicit protocols for referral or management. Biopsy was often delayed. Of 268 patients referred from primary care, referral was made to any of 14 hospital Department with 39% (105 of 268) attending more than one outpatient appointment, and 155 (41 of 268) attending more than one department. Eighteen percent (47 of 268) of patients were informed of their diagnosis within 6 weeks of referral and 42% (113 of 268) within 3 months of referral. Nine percent (24 of 268) underwent pre-operative fine needle aspiration cytology. Of patients with enlarged neck nodes, 29% (52/180) had examination of the upper aero-digestive tract.

CONCLUSIONS

The study supports the introduction of co-ordinated problem-based referral and management pathways for the management of patients with enlarged superficial lymph nodes supported by regular audits of practice.

An assessment of deprivation as a factor in the delays in presentation, diagnosis and treatment in patients with oral and oropharyngeal squamous cell carcinoma

This study explores the relationship between deprivation and patient and professional delays in presentation and treatment of oral and oropharyngeal squamous cell carcinoma. The cohort comprised 559 consecutive previously untreated patients presenting to the Regional Maxillofacial Unit, Liverpool from 1 January 1992 to 31 December 2002. All had primary surgery. The head and neck database was searched together with a review of casenotes. Deprivation was scored using the Index of Multiple Deprivation 2000 (IMD 2000) from patient post codes. PATIENT DELAY: Similar numbers of patients presented to general dental and general medical practitioners. The predominant presenting symptom was either an ulcer or swelling and 38% had symptoms for 3 or more months. Patients with shorter duration of symptoms tended to be smokers, drinkers, with lower gum and floor of mouth tumours, and more advanced disease. Primary health professional, patient age, gender, marital status, and deprivation showed no obvious correlation with patient delay. PROFESSIONAL DELAY: For 78% of patients a referral letter from GPs and GDPs was sent to the MFU on the same day as the primary consultation. There was on average about 3 weeks from referral to definitive diagnosis and about another 3 weeks before having surgery. Professional delay was shorter in patients with more advanced tumours and for patients living in the most deprived of wards. Deprivation did not seem to significantly lengthen presentation or referral however it may be that it is associated with more rapidly growing tumours.

Professional delay in head and neck cancer patients: Analysis of the diagnostic pathway

The aim of this study was to identify which factors are related to specialist delay and to determine the length of the diagnostic pathway in head and neck cancer patients. Three hundred and six patients with a carcinoma of the larynx, pharynx or oral cavity were included in the study. Logistic regression analysis was used to identify risk factors for specialist delay. Large (T3-T4) tumors showed significantly less specialist delay than small (T1-T2) tumors (p=0.045, odds ratio [OR]=0.6). Pharyngeal (p=0.00, OR=0.2) and oral carcinomas (p=0.00, OR=0.2) had less specialist delay than glottic carcinomas. Hoarseness was associated with prolonged specialist delay (p=0.00, OR=5.9). Heavy drinking in combination with smoking (p=0.005, OR=0.3), a sore throat (p=0.02, OR=0.4) or having a lesion (p=0.03, OR=0.2) showed a shorter diagnostic period. The duration of the diagnostic process in a general hospital ranged from 0 to 570 days, with a median of 14 days. Only a small group of patients met the ideal management standards in our head and neck clinic. Although prolonged delay was associated with small (glottic) tumors, the diagnostic process takes a fairly long time. The results indicate that continued educational programs for professionals are warranted.

Lymphoma: variations in time to diagnosis and treatment

This study examines illness trajectories of patients with lymphoma and assesses whether UK government targets to reduce waiting time for diagnosis and treatment are achievable and appropriate. One hundred and ninety-four patients, residents in West Yorkshire, aged more than 25 years and newly diagnosed with lymphoma during 2000 were included. Data collected from interviews, primary care and hospital records were used to examine time between critical events on the illness trajectory and characteristics of patients not meeting proposed targets. Forty-two per cent of patients did not receive a hospital appointment within 2 weeks of general practitioner referral, 26% were not treated within 1 month of diagnosis and 64% were not treated within 2 months of referral. Target achievement differed by diagnostic group, and trends were seen by age and deprivation. The interval from onset of symptoms to treatment averaged more than 1 year and approximately half of this occurred before first medical contact. Results suggest that significant improvements are needed to achieve targets. Although existing targets particularly address referral and treatment intervals, these were the shortest intervals on the trajectory. Generalized targets may be inappropriate and unachievable for lymphoma as they do not consider individual disease characteristics or allow for variations in the urgency with which treatment is needed.

Patient's delay in oral cancer: a systematic review

Detecting oral cancer at an early stage is the most effective means of improving survival and reducing morbidity from this disease, yet a significant proportion of patients delay seeking help after the self-discovery of symptoms of oral cancer. The literature on factors associated with patient delay was searched systematically to access relevant data published between 1975 and 2005. Eight studies met the inclusion criteria for the review. In these studies, most clinical/tumour factors, sociodemographic variables, and patient health-related behaviours were not related to the duration of patient delay. Healthcare factors and psychosocial factors may play a role but the research in this area is sparse, atheoretical and of poor quality. Patient delay is a problem in oral cancer and yet at present the reasons for such delays are poorly understood and under-researched. Systematic, high-quality and theory-driven research in this area is urgently required.

Oral and pharyngeal cancer: analysis of patient delay at different tumor stages

BACKGROUND

The aim of this study was to examine which factors are related to patient delay in a cohort of consecutive patients with pharyngeal cancer and oral cancer and to determine whether the different stages of patient delay (ie, appraisal, illness, behavioral, and scheduling) were related to different tumor stages.

METHODS

Before treatment, 55 patients with pharyngeal cancer and 134 patients with oral cancer were interviewed about their prediagnostic period. To verify the data, a questionnaire was sent to the general practitioner and/or dentist and a close relative.

RESULTS

Patients with a delay of more than 30 days were significantly more often diagnosed with late-stage (T3-T4) disease (pharynx, p = .01, odds ratio [OR] = 4.5; oral, p = .01, OR = 3.2). No sociodemographic characteristics were associated with patient delay.

CONCLUSIONS

Prolonged patient delay was associated with late-stage disease for both patients with pharyngeal cancer and patients with oral cancer. Although for most patients the symptoms are vague or might look like a common cold or infection, the general public should be better informed about tumor symptoms. This may enhance earlier visits to a health care professional.

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

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=+0.346, P=0.004). This was confirmed with ordinal regression modelling (delay estimate=0.045, P=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=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’.

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.

Medical care-seeking and health-risk behavior in patients with head and neck cancer: the role of health value, control beliefs and psychological distress

Health behavior plays an important role in the development, detection and course of cancer of the head and neck. Relevant health behavior includes prompt medical care seeking, and smoking and drinking cessation after diagnosis. This study examines the relationship between these health behaviors and health value and control beliefs, as well as psychological distress. Two hundred and sixty-four recently diagnosed head and neck cancer patients were interviewed about their health behavior, and they filled in a questionnaire on health beliefs and psychological distress. The results showed that one-quarter (25%) of the patients had waited more than 3 months before seeking medical care, 50% had continued to smoke and 80% had continued to drink after the diagnosis. The patients, particularly those who smoked and drank before diagnosis, reported lower levels of health value and perceived health competence than a general population sample with which they were compared. Patients who engaged in patient delay reported a lack of perceived health competence. Psychological distress and lack of perceived health competence were found to be more common among patients who continued to smoke. The implications of these findings are discussed with regard to interventions aimed at promoting these specific health behaviors.

Laryngeal cancer patients: analysis of patient delay at different tumor stages

BACKGROUND

The aim of this study was to determine the length of stages (appraisal, illness, behavioral, and scheduling) of patient delay in patients with head and neck cancer and to find out whether these delays were related to the stage of the disease at diagnosis.

METHODS

Before treatment, 117 newly diagnosed patients with laryngeal cancer were interviewed about their prediagnostic period. To determine the length of the different stages of patient delay, patients were asked about their symptoms, attributions of symptoms, and reasons to postpone medical consultation. A questionnaire was sent to the general practitioner and to a close relative to verify their answers.

RESULTS

There was no significant difference in the length of patient delay between early- (T1-T2) and advanced- stage (T3-T4) disease (9 vs 5 weeks; p = .07). Only tumor site was significantly associated with patient delay. The median total patient delays for glottic and supraglottic tumors were 10 and 4 weeks, respectively (p = .00). Hoarseness/voice change was the most commonly mentioned symptom. Patients attributed their symptom most frequently to a common cold/infection or had no idea about the cause. Medical attention was postponed because symptoms were interpreted as innocuous/benign or the symptom was thought not to be serious enough. The main reason to visit the general practitioner was persistent hoarseness. Behavioral and scheduling delays were of minor importance.

CONCLUSIONS

Patient delay was significantly longer in cases of glottic cancer, but diagnosis at an early stage of the disease was more frequent among these patients than among patients with supraglottic cancer. Advanced supraglottic cancer probably has a late onset of symptoms. Thus, earlier intervention will probably not result in a significantly higher proportion of small supraglottic cancers being diagnosed.

Patient and tumour factors associated with advanced carcinomas of the head and neck

This study identifies patient and tumour related factors associated with advanced carcinoma of the head and neck. Special attention was paid to the role of patient and professional diagnostic delays. Three-hundred and six patients newly diagnosed with carcinoma of the pharynx, larynx and oral cavity were included in the study. Logistic regression analyses were used to identify the risk factors for presenting with an advanced tumour. Multivariate analysis found that having a pharyngeal carcinoma (OR 22.68; p = .000), an oral carcinoma (OR 6.51; p = .000), or a supraglottic carcinoma (OR 8.12; p = .000), patient delay > 3 months (OR 3.47; p = .001) and having a doctors' contact for another reason than the head and neck symptom (OR 0.20; p = .022) were predictive of presenting with an advanced tumour. These results suggest that beyond tumour-related factors, the patients' care seeking behaviour contributes to an increased risk of being diagnosed with an advanced tumour of the head and neck.

Role of alcohol and smoking in diagnostic delay of head and neck cancer patients

CONCLUSIONS

This study shows that heavy drinking is a risk factor for prolonged delay in presenting with head and neck cancer and for presenting with a large tumour in the head and neck region. Excessive smoking is only a risk factor for being diagnosed with a large tumour, although there is a weak association between smoking and prolonged diagnostic delay.

OBJECTIVE

It is reasonable to assume that prolonged delay in presenting with head and neck cancer is associated with an advanced stage of cancer at diagnosis. In this study we analysed the effects of drinking and smoking habits on diagnostic delay and the T stage of the tumour at diagnosis.

MATERIAL AND METHODS

A total of 427 patients with newly diagnosed head and neck carcinomas were eligible for this study. Of these, 306 (72%) actually participated: 134 (77%) with an oral tumour; 117 (69%) with a larynx tumour; and 55 (65%) with a pharynx tumour. Diagnostic delay was defined as a period of >30 days between the appearance of the first tumour-related symptoms and the first visit to a physician. T3 4 tumours were defined as advanced tumours. Drinking behaviour was classified into three types: light (0 2 drinks/day); moderate (3 4 drinks/day); and heavy ( >4 drinks/day). Smoking habits were classified into 4 types: never; stopped; light (0 20 cigarettes/day); and heavy (>20 cigarettes/day).

RESULTS

Logistic regression showed that there were significantly more heavy than light drinkers [p = 0.04; odds ratio (OR) 1.8; 95% CI 1.0-3.1] in the delay group than in the non-delay group. Light smokers showed a tendency towards prolonged delay (p = 0.06; OR 2.2; 95% CI 1.0-5.0). Both heavy drinking (p = 0.01; OR 2.0; 95% CI 1.2-3.6) and heavy smoking (p = 0.03; OR 3.1; 95% CI 1.1-8.4) were risk factors for a patient to be diagnosed with a large tumour.

Psychological factors and patient delay in patients with head and neck cancer

There is a rising incidence of patients presenting with advanced cancer in the head and neck region. Late presentation may be due to a delay in seeking medical attention, which is sometimes surprisingly long. The aim of the present prospective study was to investigate the association between patient delay and the psychological factors of optimism, health hardiness, overall defensive functioning, coping styles and psychological distress in 277 patients with cancer of the head and neck. Significant correlations were found between patient delay and the psychological factors. Twenty-six percent of the patients waited more than three months before seeking medical attention and they reported less optimism (P = 0.0001), less health hardiness (P = 0.008), less active coping (P = 0.019) and less seeking support as a coping style (P = 0.017) than patients presenting within three months. Excessive drinkers (5+ alcoholic drinks/day) tended to show more delay than patients who did not drink or were moderate drinkers (0-2 drinks/day) or moderate-heavy drinkers (3-4 drinks/day). Together, the psychological factors could explain 25% of the variance of patient delay in excessive drinkers compared with 21% and 6% in moderate-heavy drinkers and non-drinkers to moderate drinkers, respectively. These results suggest that psychological factors affect health-care seeking behaviour. Health education aimed at the risk group of excessive drinkers should take psychological factors into account that influence their health behaviour.

An oral cancer information leaflet for smokers in primary care: results from two randomised controlled trials

OBJECTIVES

To investigate whether primary care patients who claim to smoke tobacco gain greater benefit of a patient information leaflet (PIL) on oral cancer than nonsmokers.

METHODS

Two studies were conducted. Study 1 examined the research question initially, and Study 2 acted as a replication and inclusion of additional secondary outcome measures. The leaflet was designed and tested in an earlier study. Knowledge of oral cancer was assessed by a previously validated 36-dichotomous-item scale. A single-item question ascertained self-reported smoking status (kappa = 0.94). Study 1 participants were drawn from 14 practices (6 medical, 8 dental). A randomised control group design was adopted. The experimental group received the leaflet on attendance to the practice and then completed the questionnaire. The control group received the questionnaire only. Complete data were collected from 739 respondents. The design of Study 2 was identical; 786 new respondents from 16 practices (7 medical, 9 dental) were collected.

RESULTS

Both studies confirmed that smokers knew less about oral cancer than nonsmokers (P < 0.05) when access to the leaflet had been denied. On receipt of the leaflet, there was no distinction in oral cancer knowledge between the smoking status categories of respondents. Evidence of reassurance about screening from leaflet exposure was supported by the second study.

CONCLUSION

This programmed research has demonstrated an effect of a brief PIL to offset the decrement in oral cancer knowledge observed in primary care patients who use tobacco in comparison to their nonsmoking counterparts. The leaflet reduced anxiety about oral health screening in smokers.

When does my treatment start?--The continuum of care for patients with head and neck cancer

BACKGROUND AND PURPOSE

The clinical workup of patients with head and neck (H&N) cancer is often time-consuming. The overall time involved is obviously important to the treatment results, since delays in time can increase the risk for clinical upstaging resulting in a worse outcome. Although for ethical considerations, time delay is impossible to study in randomised trials. Major reorganisations for this group of patients have taken place in Stockholm during the 1990s. In this study, we measured the duration of the overall continuum of care experienced by the patients, in different time periods during the 1990s.

MATERIALS AND METHODS

Two hundred and two patients from the population base of southern Stockholm were identified during different time periods. The continuum of care was identified as the period between the first presentation of the patient to the health care system to the first date of the patient's treatment for his/her cancer. This period was divided into several intervals reflecting the patient's perspective of his or her continuum of care. These intervals were then compared.

RESULTS

Median time from first consultation to start of treatment increased between 1994 and 1999 from 67 to 89 days (P = 0.018). The increase of time occurred from referral from first care provider to ENT-specialist, from first visit to ENT-specialist to date of diagnosis.

CONCLUSIONS

Different parameters such as duration of the continuum of care must be monitored before and after reorganisations.

Parents' accounts of obtaining a diagnosis of childhood cancer

BACKGROUND

Quick diagnosis and treatment of cancers is a UK government priority. However, the process of arriving at a diagnosis of childhood cancer has been neglected in comparison with the attention given to cancers in adults. We investigated parents' narratives about the period before their child's diagnosis.

METHODS

We undertook semistructured interviews with 20 parents whose children (aged 4-18 years) had a confirmed diagnosis of cancer or brain tumour. All interviews were recorded and fully transcribed. Dates of consultations and investigations were noted from children's medical records. Data were analysed by the constant comparison method.

FINDINGS

The time before diagnosis is very significant for parents and might affect their adaptation and reaction to their child's diagnosis. Parents were first alerted to their child's illness by a range of signs and symptoms, and by behavioural and affective changes. These early symptoms were often vague, non-specific, and common, and some older children were reluctant to disclose symptoms. Ten families' accounts of this period before diagnosis included a dispute with doctors. Disagreements between parents and doctors about the seriousness of children's symptoms and the need for investigations occurred in both primary and secondary care. Some parents felt that doctors discounted their special knowledge of their child.

INTERPRETATION

Parents' accounts offer valuable insights into their experiences of obtaining a diagnosis of childhood cancer and into possible sources of delays in this complex process. If delays are to be avoided or reduced, attention must be given to the different roles of parents, children, general practitioners, hospital specialists, and type of cancer. Our findings have important implications for policy, practice, and research, and for the management of childhood illnesses.