An epidemiological study on delay in treatment initiation of cancer patients


Early diagnosis and timely initiation of treatment of cancer patients may improve survival and quality of life. Various measures of delay can be made during diagnosis and treatment initiation. Most of the studies were based on single type of cancer with different definitions and measurements of delay in diagnosis and treatment. Thus, it has been difficult to synthesize results and generalize to other types of cancer. The study proposes to measure total duration between onsets of symptom to start of treatment into three components, namely primary, secondary and tertiary delays. Primary delay is defined as onset of symptoms to contacting the first medical person, secondary delay is from first medical contact to confirmed diagnosis, and tertiary delay is from confirmed diagnosis to treatment initiation. The aim of this study is to determine factors associated with primary, secondary and tertiary delays in cancer patients. This study was planned as a cross-sectional study. Data was collected from patients admitted to the surgical wards of Department of Surgical Oncology, Institute Rotary Cancer Hospital, New Delhi during 2006-2007. Gamma regression and quantile regressions at 25th, 50th and 75th percentile of each of the delays were used to determine related factors. A total of 403 patients were included in the analysis. The median tertiary delay was found almost two folds (59; Interquartile range: 26 - 101 days) than the primary and secondary delays. Extremity cancer patients had longest primary, secondary and tertiary delays. Shortest primary, secondary and tertiary delays were observed for gastrointestinal cancer, breast and genitourinary cancer respectively. There is an urgent need and scope to reduce delay at each level primary, secondary and tertiary delay. Intervention studies are needed through information, education and communication/screening programs to reduce the diagnostic and treatment delays in cancer patients.

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Dwivedi, A. , Dwivedi, S. , Deo, S. , Shukla, R. , Pandey, A. and Dwivedi, D. (2012) An epidemiological study on delay in treatment initiation of cancer patients. Health, 4, 66-79. doi: 10.4236/health.2012.42012.

Conflicts of Interest

The authors declare no conflicts of interest.


[1] World Health Organization (WHO) (2006) Cancer. Geneva, WHO.
[2] Neal, R.D. (2009) Do diagnostic delays in cancer matter? British Journal of Cancer, 101, 9-12. doi:10.1038/sj.bjc.6605384
[3] Korsgaard, M., Pedersen, L. and Laurberg, S. (2008) Delay of diagnosis and treatment of colorectal cancer—A population-based Danish study. Cancer Detection and Prevention, 32, 45-51. doi:10.1016/j.cdp.2008.01.001
[4] Hosseini, S.N., Mousavinasab, S.N., Moghimi, M.H. and Fallah, R. (2007) Delay in diagnosis and treatment of gastric cancer: From the beginning of symptoms to surgery—An andomi study. Turkish Society of Gastroenterology, 18, 77- 81.
[5] Pitchers, M. and Martin, C. (2006) 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. British Journal of Cancer, 94, 955-958. doi:10.1038/sj.bjc.6603044
[6] Nystrom, L., Rutqvist, L.E., Wall, S., Lindgren, A., Lindqvist, M., Ryden, S., Andersson, I., Bjurstam, N., Fagerberg, G., Frisell, J., et al. (1993) Breast cancer screening with mammography: Overview of Swedishran-domizedtrials. Lancet, 341, 973-978. doi:10.1016/0140-6736(93)91067-V
[7] Risberg, T., Sorbye, S.W., Norum, J. and Wist, E.A. (1996) Diagnostic delay causes more psychological distress in female than in male cancer patients. Anticancer Research, 16, 995-999.
[8] Almuammar, A., Dryden, C. and Burr, J.A. (2010) Factors associated with late presentation of cancer: A limited literature review. Journal of Radiotherapy in Practice, 9, 117-123. doi:10.1017/S146039690999029X
[9] Facione, N.C. (1993) Delay versus help seeking for breast cancer symptoms: A critical review of the literature on patient and provider delay. Social Science & Medicine, 36, 1521-1534. doi:10.1016/0277-9536(93)90340-A
[10] Abdo, E.N., Garrocho, A., Barbosa, A.A., Oliveira, E.L., Franca-Filho, L., Negri, S.L. and Pordeus, I.A. (2007) Time elapsed between the first symptoms, diagnosis and treatment of oral cancer patients in Belo Horizonte, Brazil. Medicina Oral Patologia Oral y Cirugia Bucal, 12, 469-473.
[11] Gorin, S.S., Heck, J.E., Cheng, B. and Smith, S.J. (2006) Delays in breast cancer diagnosis and treatment by racial/ethnic group. Archives of Internal Medicine, 166, 2244-2252. doi:10.1001/archinte.166.20.2244
[12] Salomaa, E.R., Sallinen, S., Hiekkanen, H. and Liippo, K. (2005) Delays in the diagnosis and treatment of lung cancer. Chest, 128, 2282-2288. doi:10.1378/chest.128.4.2282
[13] Allgar, V.L. and Neal, R.D. (2005) Delays in the diagnosis of six cancers: Analysis of data from the national survey of NHS patients: Cancer. British Journal of Cancer, 92, 1959-1970. doi:10.1038/sj.bjc.6602587
[14] Gwyn, K., Bondy, M.L., Cohen, D.S., Lund, M.J., Liff, J.M., Flagg, E.W., Brinton, L.A., Eley, J.W. and Coates, R.J. (2004) Racial differences in diagnosis, treatment, and clinical delays in a population-based study of patients with newly diagnosed breast carcinoma. Cancer, 100, 1595-1604. doi:10.1002/cncr.20169
[15] Look, M., Tan, Y.Y., Vijayan, A., The, C.H. and Low, C.H. (2003) Management delays for early gastric cancer in a country without mass screening. Hepatogastroenterology, 50, 873-876.
[16] Amir, Z., Kwan, S.Y., Landes, D., Feber, T. and Williams, S.A. (1999) Diagnostic delays in head and neck cancers. European Journal of Cancer Care, 8, 198-203. doi:10.1046/j.1365-2354.1999.00165.x
[17] Caplan, L.S. and Helzlsouer, K.J. (1992) Delay in breast cancer: A review of the literature. Public Health Reviews, 20, 187-214.
[18] Tjemsland, L. and Soreide, J.A. (2004) Operable breast cancer patients with diagnostic delay—Oncological and emotional characteristics. European Journal of Surgical Oncology, 30, 721-727. doi:10.1016/j.ejso.2004.05.005
[19] Hansen, R.P., Olesen, F., Sorensen, H.T., Sokolowski, I. and Sondergaard, J. (2008) Socioeconomic patient characteristics predict delay in cancer diagnosis: A Danish cohort study. BMC Health Services Research, 8, 49-59. doi:10.1186/1472-6963-8-49
[20] Kumar, S., Heller, R.F., Pandey, U., Tewari, V., Bala, N. and Oanh, K.T. (2001) Delay in presentation of oral cancer: A multifactor analytical study. National Medical Journal of India, 14, 13-17.
[21] Love, N. (1991) Why patients delay seeking care for cancer symptoms. What you can do about it. Postgraduate Medicine, 89,151-158.
[22] Kantola, S., Jokinen, K., Hyrynkangas, K., Mantyselka, P. and Alho, O.P. (2001) Detection of tongue cancer in primary care. Journal of the Royal College of General Practitioners, 51, 106-111.
[23] Lynch, B.M., Baade, P., Fritschi, L., Leggett, B., Owen, N., Pakenham, K., Newman, B. and Aitken, J.F. (2007) Modes of presentation and pathways to diagnosis of colorectal cancer in Queensland. The Medical Journal of Australia, 186, 288-291.
[24] Allison, P., Franco, E. and Feine, J. (1998) Predictors of professional diagnostic delays for upper aerodigestive tract carcinoma. Oral Oncology, 34, 127-132. doi:10.1016/S1368-8375(97)00078-X
[25] Habermann, W., Berghold, A., Devaney, T.T. and Friedrich, G. (2001) Carcinoma of the larynx: Predictors of diagnostic delay. The Laryngoscope, 111, 653-656. doi:10.1097/00005537-200104000-00018
[26] Tromp, D.M., Brouha, X.D., Hordijk, G.J., Winnubst, J.A. and De Leeuw, J.R. (2005) Patient factors associated with delay in primary care among patients with head and neck carcinoma: A case-series analysis. Family Practice, 22, 554-559. doi:10.1093/fampra/cmi058
[27] Barber, M.D., Jack, W. and Dixon, J.M. (2004) Diagnostic delay in breast cancer. British Journal of Surgery, 91, 49-53. doi:10.1002/bjs.4436
[28] Pitiphat, W., Diehl, S.R., Laskaris, G., Cartsos, V., Douglass, C.W. and Zavras, A.I. (2002) Factors associated with delay in the diagnosis of oral cancer. Journal of Dental Research, 81, 192-197. doi:10.1177/154405910208100310
[29] Abdel-Fattah, M.M., Anwar, M.A., Mar, E., El-Shazly, M.K., Zaki, A.A., Bedwani, R.N. and Nicolucci, A. (1999) Patient- and system-related diagnostic delay in breast cancer Evidence from Alexandria, Egypt. European Journal of Public Health, 9, 15-19. doi:10.1093/eurpub/9.1.15
[30] Montella, M., Crispo, A., D’aiuto, G., De Marco, M., De Bellis, G., Fabbrocini, G., Pizzorusso, M., Tamburini, M. and Silvestra, P. (2001) Determinant factors for diagnostic delay in operable breast cancer patients. European Journal of Cancer Prevention, 10, 53-59. doi:10.1097/00008469-200102000-00006
[31] Dodd, S., Bassi, A., Bodger, K. and Williamson, P. (2006) A comparison of multivariable regression models to analyse cost data. Journal of Evaluation in Clinical Practice, 12, 76-86. doi:10.1111/j.1365-2753.2006.00610.x
[32] National Institute of Family and Welfare (2003) National Cancer Control Programme.
[33] Esteva, M., Ramos, M., Cabeza, E., Llobera, J., Ruiz, A., Pita, S., Segura, J.M., Cortes, J.M. and Gonzalez-Lujan, L. (2007) Factors influencing delay in the diagnosis of colorectal cancer: A study protocol. BMC Cancer, 85, 272-276.
[34] Onizawa, K., Nishihara, K., Yamagata, K., Yusa, H., Yanagawa, T. and Yoshida, H. (2003) Factors associated with diagnostic delay of oral squamous cell carcinoma. Oral Oncology, 39, 781-788. doi:10.1016/S1368-8375(03)00075-7
[35] Norsa’adah, B., Rampal, K.G., Rahmah, M.A., Naing, N.N. and Biswal, B.M. (2011) Diagnosis delay of breast cancer and its associated factors in Malaysian women. BMC Cancer, 11, 141-149. doi:10.1186/1471-2407-11-141
[36] Arndt, V., Sturmer, T., Stegmaier, C., Ziegler, H., Becker, A. and Brenner, H. (2003) Provider delay among patients with breast cancer in Germany: A population-based study. Journal of Clinical Oncology: American Society of Clinical Oncology, 21, 1440-1446. doi:10.1200/JCO.2003.08.071
[37] Neal, R.D. and Allgar, V.L. (2005) Sociodemographic factors and delays in the diagnosis of six cancers: Analysis of data from the “national survey of NHS patients: Cancer”. British Journal of Cancer, 92, 1971-1975. doi:10.1038/sj.bjc.6602623
[38] Khoo, S.P., Shanmuhasuntharam, P., Mahadzir, W.M., Tay, K.K., Latif, A. and Nair, S. (1998) Factors involved in the diagnosis of oral squamous cell carcinoma in Malaysia. Asia-Pacific Journal of Public Health, 10, 49-51. doi:10.1177/101053959801000111
[39] Koivunen, P., Rantala, N., Hyrynkangas, K., Jokinen, K. and Alho, O.P. (2001) The impact of patient and professional diagnostic delays on survival in pharyngeal cancer. Cancer, 92, 2885-2891. doi:10.1002/1097-0142(20011201)92:11<2885::AID-CNCR10119>3.0.CO;2-G
[40] Ozlu, T., Bulbul, Y., Oztuna, F. and Can, G. (2004) Time course from first symptom to the treatment of lung cancer in the eastern black sea region of turkey. Medical Principles and Practice, 13, 211-214. doi:10.1159/000078318
[41] Radzikowska, E., Roszkowski, K. and Glaz, P. (2001) Lung cancerdiagnosis and therapy delay. Pneumonologia i Alergologia Polska, 69, 600-610.
[42] Khattak, I., Eardley, N.J. and Rooney, P.S. (2006) Colorectal cancera prospective evaluation of symptom duration and GP referral patterns in an inner city teaching hospital. Colorectal Disease, 8, 518-521. doi:10.1111/j.1463-1318.2006.00967.x
[43] Wang, J., Liu, F., Gao, H., Wei, W., Zhang, X., Liang, Y. and Cheng, Y. (2008) The symptom-to-treatment delay and stage at the time of treatment in cancer of esophagus. Japanese Journal of Clinical Oncology, 38, 87-91. doi:10.1093/jjco/hym169
[44] Langenbach, M.R., Schmidt, J., Neumann, J. and Zirngibl, H. (2003) Delay in treatment of colorectal cancer: Multifactorial problem. World Journal of Surgery, 27, 304-308. doi:10.1007/s00268-002-6678-9
[45] Wallace, D.M., Bryan, R.T., Dunn, J.A., Begum, G. and Bathers, S. (2002) Delay and survival in bladder cancer. BJU International, 89, 868-878. doi:10.1046/j.1464-410X.2002.02776.x
[46] Ashwood, N., Witt, J.D., Hallam, P.J. and Cobb, J.P. (2003) Analysis of the referral pattern to a supraregional bone and soft tissue tumour service. Annals of the Royal College of Surgeons of England, 85, 272-276. doi:10.1308/003588403766275015
[47] Subramonian, K.R., Puranik, S. and Mufti, G.R. (2003) How will the two-weeks-wait rule affect delays in management of urological cancers? Journal of the Royal Society of Medicine, 96, 398-409. doi:10.1258/jrsm.96.8.398

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