Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
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Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : May | Volume : 16 | Issue : 5 | Page : MC04 - MC09 Full Version

An Observational Cross-sectional Study of Factors Causing Delay in Diagnosis of Head and Neck Cancers at a Rural Tertiary Care Centre in Northern India


Published: May 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/53086.16392
Neha Salaria, Uma Garg, Mitva Agarwal, Swaran Kaur

1. Associate Professor, Department of Ear, Nose and Throat, Bhagat Phool Singh Government Medical College, Sonepat, Haryana, India. 2. Professor, Department of Ear, Nose and Throat, Bhagat Phool Singh Government Medical College, Sonepat, Haryana, India. 3. Resident, Department of Ear, Nose and Throat, Bhagat Phool Singh Government Medical College, Sonepat, Haryana, India. 4. Professor and Head, Department of Pathology, Bhagat Phool Singh Government Medical College, Sonepat, Haryana, India.

Correspondence Address :
Mitva Agarwal,
Room No. 10, JR Female Hostel, Bhagat Phool Singh Government Medical College, Khanpur Kalan, Sonepat, Haryana, India.
E-mail: mitva15july@gmail.com

Abstract

Introduction: Cancer is a complex genetic disease derived from the accumulation of a variety of genetic changes, which include activation of proto-oncogenes and inactivation of tumour suppressor genes. Head and Neck Cancers (HNC) are rapidly growing tumours with a median potential doubling time of only 6-7 days. Although these cancers are easily accessible, patients rarely present early. In India, most HNCs present in advanced stages resulting in increased morbidity and mortality. Hence, it is prudent to ascertain the factors which lead to delay in diagnosis of HNC as early diagnosis and treatment is the cornerstone in reducing consequences of HNC.

Aim: To identify patient and professional factors causing delay in diagnosis of HNC and to identify association if any with stage of cancer presentation.

Materials and Methods: An observational cross-sectional study was conducted in the Department of Ear Nose and Throat, at BPS Government Medical College for women, Sonepat, Haryana, India, from September 2019 to January 2021. Study included 55 newly diagnosed histopathologically confirmed head and neck cancer patients. Clinico-demographic details were inferred using elaborate clinical examination. Data were described in terms of range, mean±Standard Deviation (SD), frequency and relative frequency (percentages). Chi-square and Fisher’s-exact test was used for comparing categorical data. Delay due to patient and professional factors were calculated separately and the association of each delay with important variables were compared.

Results: Total 55 newly diagnosed histopathologically proven primary HNC patients were included in the study. Most patients (43.6%) belonged to the age group of 51 to 60 years, and the mean age was 60.25±9.81 years. Majority of the patients were males (85.5%). The mean total delay from onset of symptoms to final diagnosis was 22.38±7.23 weeks. Delayed patient presentation was the main cause of total delay in diagnosis. The main factors responsible for patient delay were rural residential status, low formal education, socio-economic status and poor cancer awareness. Irrational therapies still contributed significantly for delayed patient presentation. Diagnostic delay led to upstaging of disease.

Conclusion: Patient delay is the main factor responsible for delay in diagnosis of HNC. Even in this era of easy availability and accessibility of information, lack of awareness still exists at the fundamental level.

Keywords

Patient delay, Professional delay, Stage, Tumour

Cancer is a complex genetic disease derived from the accumulation of a variety of genetic changes, which include activation of proto-oncogenes and inactivation of tumour suppressor genes (1). About 90% Head and Neck Carcinomas (HNC) are squamous cell carcinomas of the mucosa of the upper aerodigestive tract (2),(3),(4). These include cancers of the oral cavity, oropharynx, nasopharynx, hypopharynx, larynx, nasal cavity and paranasal sinuses (5).

An estimated 2.1 million cases and 1 million deaths were attributed to HNC worldwide as per International Agency for Research on Cancer in 2020, contributing to 11% incidence of total body cancers and 10.6% of global cancer mortality (6). Head and neck carcinomas exists globally but its prevalence is more in the Asian population. Total 57.5% of the global HNCs occur in Asia, 30-35% of which occur in India (7).

The high incidence of HNCs, especially oral and oropharyngeal cancers in the Indian community could be attributed to the role of tobacco in several forms, particularly in the form of bidi smoking (locally made tobacco rolled in betel leaf) and alcohol in the aetiology of HNC, the practice of which is widely rampant in the Indian population (8),(9).

The HNCs are rapidly growing tumours with a median potential doubling time of only 6-7 days (10). Although these cancers are easily accessible, patients rarely present early (10). In India, 60 to 70% of HNCs present in the advanced stages resulting in increased morbidity and mortality (9). It has been noted that the survival rates of HNC are widely variable in different communities, being lower in resource limited countries than developed ones (3).

Delay in diagnosis of HNC could occur at the level of patient, primary physician or final diagnosis. Patient delay is the interval between the patient first noticing his symptoms and consulting a healthcare professional (3). Professional delay refers to the time interval between the patient’s first consultation with a healthcare professional through final histopathological diagnosis to initiation of treatment. This includes doctor/practitioner/Primary Health Centre (PHC) delay which is the interval between first consultation and referral to a specialist trained in managing such cases (11),(12),(13),(14) and system/hospital/specialist delay, which is the interval between first consultation with a specialist through final histopathological diagnosis to treatment initiation (3),(8),(11),(12),(13),(14),(15).

This study was henceforth undertaken as an attempt to ascertain the factors which led to delay in diagnosis of HNC as early diagnosis and treatment is the cornerstone in reducing consequences of HNC. Any delay may lead to advancement of stage requiring radical and disfiguring surgical treatment, recurrence of disease and adversely impacting quality of life (16),(17),(18),(19),(20).

Material and Methods

An observational cross-sectional study was conducted on 55 newly diagnosed patients of primary HNC who presented in the Department of Ear, Nose and Throat, at BPS Government Medical College for women, Sonepat, Haryana, India. The study was undertaken from September 2019 to January 2021, after obtaining Ethical Committee approval (vide letter no. BPSGMCW/RC509/IEC/18).

Sample size calculation: Using n-Master 2.0 software, sample size based on the prevalence of head and neck cancer as 21.5% with 5% absolute error and 95% confidence interval, the required sample size was 55 (21). Consecutive sampling technique was used in the study.

Inclusion criteria: All histopathologically proven cases of primary head and neck cancer were included in the study.

Exclusion criteria: Synchronous malignancy, recurrent malignancy, non consenting patients were excluded from the study.

Procedure

The suspected patient’s demographic details regarding age, gender, residential, educational and socio-economic status were recorded. No formal education was defined as “illiterates”, primary/middle school certificate was defined as “low formal education”, and high school certificate/diploma as “formal education”.

Questionnaire: Informed and written consent was taken followed by a personal interview questionnaire in the local language enquiring about the type, onset and duration of symptoms. A cancer awareness questionnaire was used to assess the level of cancer awareness in the patients (21). The questions included were:

1. Do you know about cancer?
2. What causes cancer of aerodigestive tract?
3. What are the signs of these cancers?
4. Can you prevent cancer?
5. Where do you go for suggestion, doubts and treatment of cancer?

If three out of the five questions were answered, the patient was assumed to have good cancer awareness, a lesser score indicated poor awareness. Personal history was recorded and details about addictions were noted. Date and type of first consultation and irrational/unregistered therapies were taken, professional consultations and their type were recorded and confirmed.

A high index of suspicion regarding malignancy was maintained and a thorough clinical and radiological evaluation was done. Clinical suspects were then taken for biopsy and histopathological assessment. The date of biopsy and receipt of histopathology report was also recorded. If repeat biopsies were taken, a note was made regarding them.

TNM staging: Tumours were staged as per the Tumour Node Metastasis (TNM) System of Classification as per the American Joint Committee on Cancer (AJCC) and Union for International Cancer Control (UICC) 8th edition into stage I, II, III and IV. Stage I and II were grouped into early-stage cancer and stage III and IV were grouped into advanced stage cancer (22).

Patient delay: The patient delay was defined as the time interval between the perception of the first symptoms by the patient and the first consultation with a registered healthcare professional. Time taken for undergoing irrational/unregistered therapies was included in this.

Professional delay: The professional delay was defined as the duration between the patient’s first consultation with a healthcare professional and confirmatory histopathological diagnosis. This incorporated Primary Health Centre (PHC) and system delay. The PHC delay was the duration when the patient approached their primary registered physician until contact with specialist for definitive diagnosis. System delay was calculated as the duration between the first specialist outpatient visit and confirmatory histopathological diagnosis.

All delays were calculated in weeks. Total delay was divided into 4 groups- less than 10 weeks, 10-20 weeks, 20-30 weeks and 30-40 weeks and proportion of patients in each group was determined. All variables were analysed to determine their association with patient, professional and total delay.

Statistical Analysis

The collected data were entered in Microsoft Excel spreadsheet. Data were described in terms of range, mean±standard deviation, frequency and relative frequency (percentages). To determine whether the data were normally distributed, a Kolmogorov-Smirnov’s test was used, comparison of quantitative variables between the study groups was done using Mann-Whitney’s U-test and Kruskal-Wallis test. Chi-square test was performed and Fisher’s-exact test was used for comparing categorical data. A probability value (p-value) <0.05 was considered statistically significant. All statistical calculations were done using Statistical Package for Social Sciences (SPSS) version 21.0 (SPSS Inc., Chicago, IL, USA) statistical program.

Results

Total 55 newly diagnosed histopathologically proven primary HNC patients were included in the study. Most patients (43.6%) belonged to the age group of 51 to 60 years, and the mean age was 60.25±9.81 years. Majority of the patients were males (85.5%). Regarding demography, most patients belonged to rural background, and had no formal education, although, 67.3% patients had good cancer awareness. Large proportion of patients had some form of addiction with smoking being most encountered (Table/Fig 1).

Oropharyngeal cancer (67.3%) was the most commonly occurring followed by laryngeal cancer. All cases had squamous cell carcinoma with most commonly noted pathological grade being moderately differentiated carcinoma. Early stage cancer was seen in 40% patients (stage I: 14.5% and stage II: 25.5%) while 60% patients presented with advanced stage cancer (stage III: 34.5% and stage IVa: 25.5% patients). Vast proportion of laryngeal and oropharyngeal cancers presented in advanced stages in contrast to early presentation in oral cancers (Table/Fig 1).

About 60% patients had a previous non professional visit for unregistered/irrational therapies before presenting to a registered healthcare practitioner. The mean patient delay was 19.2±7.38 weeks, which was inclusive of this non professional consultation which accounted for about 3.85 weeks (Table/Fig 2).

The mean total professional delay (PHC and system delay) was found to be 3.18±2.16 weeks and ranged from 0.7 to 11 weeks. The mean PHC delay was 0.44±1.42 weeks. The system delay was 2.75±1.62 weeks and comprised of summation of time expended for taking and reporting biopsy, which was further compounded if repeat biopsies were taken. The mean duration taken to prepare a patient for biopsy of the lesion (biopsy procedure delay) was 1.56±1.49 weeks, and to prepare a histopathological report was 1.15±0.64 weeks. Mean delay due to repeat biopsy added 0.04±0.19 weeks. The mean total delay including patient and entire professional delay was 22.38±7.23 weeks (Table/Fig 2).

Upon evaluation of the relation between patient delay with various demographic and clinical characteristics, significant association was perceived with educational, residential and socio-economic status, cancer awareness and composite stage (Table/Fig 3). The non professional consultation delay contributed largely to patient deferral was found to be significantly associated with educational level, socio-economic status, and composite stage. Patients belonging to lower socio-economic and educational strata postponed institutional treatment by seeking irrational/unregistered therapies. This inturn led to upstaging of disease (Table/Fig 4).

A median patient delay of 20 weeks was observed in rural, while it was found to be 22 weeks in those with no formal education. The patient delay decreased with improving educational and socio-economic status. Similarly, cancer awareness had a significant relation on patient delay with higher delay for patients with poor cancer awareness and lower for those with good cancer awareness (Table/Fig 3).

The professional delay was not found to be significantly associated with age, gender, residential, educational or socio-economic status, cancer awareness, smoking or drinking habits, site of lesion and cancer stage. Upon studying the total delay with various factors, it was found to be significantly associated with residential, educational and socio-economic status, cancer awareness and composite stage. Median total delay was 26.4 weeks for patients with no formal education, 17.3 weeks for patients with low formal and 14 weeks for patients with formal education. Cancer awareness was also significantly associated with total delay, which was higher for patients with no cancer awareness (Table/Fig 5).

It was also found that 46 (83.6%) of the cancer patients fell in the category of delay group 10 to 20 weeks and 20 to 30 weeks which is quite a substantial delay period for a disease like cancer.

Discussion

The prognosis of HNCs predominantly depends on the stage of tumour at presentation (23). Hence there is dire need of timely diagnosis and initiation of treatment which can reduce avoidable morbidity, mortality and huge treatment costs thereby leading to a better quality of life. In a country like India, where a sizeable population is exposed to the known risk factors like tobacco, betel quid and alcohol, it is prudent to identify factors which contribute to diagnostic delay of HNCs. This observational cross-sectional study was an attempt to recognise such factors causing delay in diagnosis so that effective timely interventions can be undertaken.

Demographics: In the present study, the mean age of the patients was 60.25 years and the study population comprised mainly of males, greater part of whom were from rural background with no formal education. Cancer awareness has been thought to play a major role in self-identification of symptoms and a considerable 67.3% of patients enrolled had good cancer awareness. The importance of cancer awareness in this study cannot be over emphasised. Joshi P et al., in their oral cancer study observed that 85% of the patients had noticed their oral lesion themselves. However, due to lack of cancer awareness, kept on ignoring their symptoms and did not present to a healthcare practitioner (24).

Oropharyngeal cancer was the most common site and all cases were reported to be of squamous cell variety, with moderately differentiated carcinoma being the most widely noted pathological grade. Total 40% patients presented with early stage cancer while 60% patients presented with advanced stage cancer in the current study. Agarwal AK et al., observed comparable findings, whereas Krishnatreya M et al., observed 49% advanced cancers in their study (4),(25). The major determinant of patient survival in HNC is the stage of the tumour at patient presentation. One of the major goals to identify factors responsible for delaying diagnosis is to decrease such late grade of presentation of HNCs which thereby cause more morbidity and mortality. Mean patient, professional and total delay was found to be 19.2 weeks, 3.18 weeks and 22.38 weeks respectively.

Patient delay: Patient delay was hence the main source of total delay in diagnosis of HNC at the present centre. Factors leading to patient delay were low educational and socio-economic status, rural residence as well as inadequate cancer awareness. Delayed presentation was also associated with upstaging of disease. The mean duration of complaints was 15.35 weeks and the patients took a mean time period of 3.85 weeks in seeking irrational/unregistered treatments before presenting to a healthcare practitioner. The patient delay was found to be significantly associated with residential status, educational status, socio-economic status, cancer awareness and stage of disease.

Patients from rural areas had a median patient delay of 20 weeks compared to that of 13.5 weeks for patients from urban areas. Inspite of the centre being located in rural heartland, delayed patient presentation was quite significantly observed in the patients. This can be ascribed to delayed symptom appraisal and low health seeking behaviour for people living in rural parts of India. Alahapperuma LS and Fernando EA in their Srilankan study, identified no effect of rural residence on delay in patient presentation and this was attributed to the universal accessibility of healthcare services in their country (12).

Regarding education and socio-economic status, inverse relation was seen with delay i.e., as education/socio-economic status decreased, delay increased. This could be attributed to inability to comprehend the gravity of the symptoms or not prioritizing health inspite of having unrestricted tertiary level treatment at government institutes. Similar observations were made by Krishnatreya M et al., (25). However, patients with good cancer awareness presented to a healthcare practitioner with a median delay of 16 weeks compared to 25 weeks in others. Yu T et al., reported a low median patient delay of 4.5 weeks as two-thirds of these subjects visited their dentist annually, giving an insight into the high cancer awareness of the study population and accounting for the low patient delay (13). Gilyoma JM et al., (5), Joshi P et al., (24) and Akram M et al., (14) also reaffirmed findings analogous to the current study and identified lack of cancer awareness as the leading cause of patient delay. Cancer awareness is an easily amendable factor in the Indian scenario, cognizance could be brought about by door-to-door health workers or awareness camps at the basic or community level.

Although it was noted that patients with oropharyngeal cancers deferred presentation more as compared to other cancers, this was not found to be statistically significant in our study. This observation is supported by studies of Brouha XD et al., and Allison P et al., who found longer patient delay in oropharyngeal cancers than that for oral cancer, owing to the lack of eminent symptoms in early stages of oropharyngeal cancer (19),(26).

Another imperative observation was that delayed patient presentation also led to upstaging of the disease. Early cancers were associated with a median patient delay of 13 weeks as compared to 24 weeks in advanced cancers. Certain other studies also support this finding and hence it can be clinched that patient delay significantly affected the stage at presentation (3),(12),(17),(19),(25).

Irrational/unregistered treatments (non professional consultation) delay were a noteworthy part of patient delay. It was observed that 60% patients sought irrational therapies first and then presented to a healthcare practitioner. Low educational and socio-economic status was significantly associated with seeking alternate therapy (Table/Fig 5) which also led to significant upstaging of disease. The practice of seeking irrational treatments is infact so widespread that even cancer awareness did not play a significant role in preventing this behaviour. This could be accredited to widespread cultural and religious beliefs leading to practice of seeking such unregistered treatments. Gilyoma JM et al., similarly noted that 61.8% of the patients sought traditional therapy before presenting to the healthcare practitioner (5). This rife practice of seeking treatment from unregistered practitioners is alarming, however this belief could be taken advantage of and such traditional practitioners could be incorporated as they are point of first contact in several Indian communities. Adequate training should be provided to them so as to not only identify but also notify cancerous symptoms which could help overcome this substantial barrier.

Professional delay: The professional delay was taken as a sum of PHC and system delay. The mean time taken for referral of a patient from primary health physician was 0.44 weeks, while the mean system delay was found to be 2.75 weeks resulting in a mean professional delay of 3.18±2.16 weeks. The professional delay was not found to be significantly associated with age, gender, locality of residence, educational status, socio-economic status, cancer awareness, smoking or drinking habits, site of lesion or composite stage.

The median professional delay although insignificant, was maximum for laryngeal cancer. This can be attributed to the need of specialised procedures such as endoscopic setup for diagnosis which are neither readily available at PHC level nor are all general physicians trained to perform such simple outpatient procedures conventionally. System delay could be ascribed to the fact that laryngeal growth obligated biopsy under general anaesthesia more often than other sites, which necessitates tedious time used for patient preparation.

Nieminen M et al., identified a longer professional delay due to false benign cytological and histopathological findings at the PHC level, multiple visits and delayed referral from PHC to specialist. Also, the time to treatment initiation was included in the professional delay, making it longer than the present study (18). Study by Esmaelbeigi F et al., also by Lee SC et al., Yu T et al., and Joshi P et al., reported a higher mean professional delay owing to higher referral delay and lack of high index of suspicion on the part of the specialist (3),(11),(13),(24).

The professional delay at the primary level ought to be tackled as this is a factor which can be readily obliterated through proper training and supply of facilities at the primary healthcare level. With the advent of flexible endoscopes, evaluation can be safely handled at the outpatient level by the primary healthcare physicians. Symptom identification in high-risk groups alongwith training and workshops regarding evaluation and diagnosis of such patients could be highly beneficial. Moreover, it could help reduce load on the tertiary level facilities as referral could be reduced resulting in streamlining of patient influx thereby causing decrease in system delay too.

Total delay: Mean total delay in present study was 22.38 weeks and patient delay was found to be the main factor accountable. The total delay was found to be significantly associated with residential, educational and socio-economic status, cancer awareness and stage.

Ganesan S et al., interestingly ascertained that both patient and professional delay contributed equally to the total delay. They attributed the shorter patient delay to the readily accessible health services in addition to high literacy levels in the study area (15). A Srilankan study found mean total delay as 14.1±10.9 weeks in their study which was fairly low, crediting this to free healthcare services and universal accessibility of health services there (12).

In substantiation, Akram M et al., found patient delay as the main cause of diagnostic delay in HNC. The factors found significantly associated with patient delay were rural residence, lower socio-economic status, seeking alternate therapy and low cancer awareness analogous to the present study (14). Saleem Z et al., (20), Kowalski LP and Carvalho AL (16), Agarwal AK et al., (4) and Lee SC et al., (11) also corroborate and conclude patient delay as the main cause of delayed diagnosis.

To summarize, this study helped us to clinch that delayed patient presentation is the main cause of delay in diagnosis of HNC. Patient delay was furthermore significantly associated with residential, educational and socio-economic status, cancer awareness as well as upstaging of disease. The practice of seeking irrational/unregistered therapies is still widespread and forms a major reason of patient delay. This delay led to upstaging of disease which would lead to increased morbidity and mortality. There is thereby need to overcome readily modifiable factors by collective effort of not only treating physicians but also primary care physicians, unregistered practitioners, healthcare or fundamental workers as well, to incite early diagnosis and improve prognosis of cancer patients.

Limitation(s)

The sample size was limited owing to a small proportion of patients reporting with head and neck cancer. Although the study population was adequate for the stipulated time frame, a larger study would have given more statistically significant results. Multicentric trial would also aid in not only a greater sample size but also overcome and ascertain the geographical limitations pertaining to a single centre study. Nevertheless, the current study achieved potentially useful new insight regarding delay factors in a readily accessible rural tertiary care centre and warrants special attention.

Conclusion

To conclude, patient delay is the main factor responsible for delay in diagnosis of HNC. To curtail these factors is a daunting task but still a feasible target. Even in this era of easy availability and dispersibility of information, awareness still lacks at the basic level where patients are unable to access the designated free rural tertiary health centres for early diagnosis. This can be overcome by door-to-door drives by healthcare and ground level workers, awareness campaigns and taking into confidence and involving other non registered practitioners. There is also need to provide diagnostic amenities and appraisal at primary care physician levels to aid early diagnosis and decrease morbidity and mortality related to this menacing disease.

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DOI and Others

DOI: 10.7860/JCDR/2022/53086.16392

Date of Submission: Oct 30, 2021
Date of Peer Review: Dec 30, 2021
Date of Acceptance: Feb 17, 2022
Date of Publishing: May 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Nov 01, 2021
• Manual Googling: Jan 31, 2022
• iThenticate Software: Apr 29, 2022 (5%)

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