Investigation into the Potential Sources of Delay in the Management of Patients with Oral Squamous Cell Carcinoma
There has been minimal change in the prognosis for patients diagnosed with oral squamous cell carcinoma (OSCC) over the past several decades. This is certainly influenced by the fact that many patients have late stage disease by the time they are seen by the head and neck cancer team. There seems to be a significant opportunity to improve the prognosis of OSCC by reducing the proportion of patients with late stage disease. It has been demonstrated that dental professionals are more likely than physicians to detect OSCC at an earlier stage.1
Objective:
The purpose of this study was to investigate the potential sources of delay in the diagnosis and management of OSCC in a Canadian oral and maxillofacial surgery practice.
Patients and Methods:
This retrospective study included all newly diagnosed OSCC patients that were referred to the Oral and Maxillofacial Surgery (OMFS) service of the Queen Elizabeth II Health Sciences Centre in Halifax, Nova Scotia from January 2005 to August 2011. Timeframes pertaining to patient care were collected from patient records, from onset of symptoms through to surgical management. Timeframes were compared for early and late stage OSCC patients using parametric and non-parametric statistics. The written referrals pertaining to each case were also assessed for their associated urgencies and suspicions of cancer. Comparisons were made between referral letters from dentists and referral letters from physicians.
Results:
There were 60 patients diagnosed with OSCC in the study period. Sixty-two percent of the subjects were male. The mean age was 61 years (range = 33 to 95 years) and 45% had a history of tobacco smoking. Over eighty percent of the subjects complained of pain related to the OSCC at the time of diagnosis.
The single longest timeframe delaying the diagnosis was from the onset of symptoms to the time of presentation to a medical/dental professional with a mean of 94.7 days (range = 1 to 395 days). Patient delay has been identified as a prominent factor in other literature.2 The only statistically significant difference in comparing timeframes for early versus late stage disease patients was that from the date of referral by the primary care provider to the date the subject was seen by the OMF surgeon (p=0.004). Patients with early stage disease were seen a mean of 20 days from the date of referral whereas late stage patients were seen a mean of 7 days from the date of referral.
Seventy-five percent of referrals were from the dental community with the remainder coming from the medical community. There was no statistically significant difference in the proportion of dentists (59.4%) versus physicians (55.6%) indicating a level of urgency on the referral letter. Nor was there a statistically significant difference in the proportion of dentists (37.5%) versus physicians (33.3%) indicating a suspicion of OSCC on the referral.
Conclusions:
Potential sources of delay in the management of patients with OSCC include:
- Patient delay in recognizing the signs and symptoms of OSCC and presenting to a health care provider.
- The ability of dental and medical professionals to recognize the signs and symptoms of OSCC.
- Referral letters from dental and medical professionals who are suspicious of OSCC, which fail to clearly indicate those suspicions.
References:
- Holmes, J.D., Dierks, E.J., Homer, L.D., Potter, B.E. Is Detection of Oral and Oropharyngeal Squamous Cancer by a Dental Health Care Provider Associated With a Lower Stage at Diagnosis? Journal of Oral and Maxillofacial Surgery, 2003; 61: 285.
- Yu, T., Wood, R.E., Tenenbaum, H.C. Delays in Diagnosis of Head and Neck Cancers. Journal of the Canadian Dental Association, 2008; 24(1): 61.