Influence of "diagnostic delay" upon cancer survival: an analysis of five tumour sites.

Abstract

STUDY OBJECTIVE--The aim was to assess the relationship between survival, tumour stage, and the interval from first symptom to diagnosis (SDI, or duration of symptoms). DESIGN--This was a retrospective follow up study of a cohort of patients registered in the tumour registry of the Hospital del Mar (Barcelona). SETTING--Hospital based tumour registry, with patients derived mainly from the City of Barcelona. PARTICIPANTS--1247 cases of lung, breast, stomach, colon, or rectal cancer were analysed using survival curves and Cox proportional hazards regression. Subjects (mean age 63.6 years) were followed for a median length of 12.9 months after diagnosis. At the time of diagnosis one fourth of patients had disseminated disease. MEASUREMENTS AND MAIN RESULTS--Based on clinical records, a physician registered the onset time of the first symptom attributable to cancer (from which the SDI is computed), as well as the tumour stage at diagnosis. Other measurements followed standard tumour registry procedures. Overall, the crude mean SDI was 5.15 months (SD 8.03, median 2.03); only 24.5% of cases had an SDI less than a month. Crude mean SDIs by anatomical site were as follows: lung cancer 3.07 months; breast 7.44; stomach 5.34; colon 5.74; rectum 5.03. Tumour extension did not appear to be significantly influenced by SDI, only breast cancer showing a distinct pattern of increased extension with increasing SDI. As expected, the probability of survival decreased monotonically with increasing stage in all sites. Tumour site was also a significant predictor of survival, which at one year ranged from 93% for breast cancer to 28% for lung cancer. However, a longer SDI tended sometimes to be associated with a better chance of survival, a fact that was most apparent in colon cancer. All Cox proportional hazards models showed a consistent picture: SDI was not a significant predictor of survival (age and sex adjusted hazard ratios ranging from 0.97 to 1.01), neither was sex; age did predict survival, and so did site and stage. CONCLUSIONS--The results provide further evidence of a very weak relationship between SDI and tumour stage at diagnosis (except for breast cancer), and between SDI and survival, thus emphasising some limitations within which early clinical detection operates. They also suggest that in addition to reflecting patient and physician behaviour, as well as the functioning of the health system, SDI may be influenced by the biological behaviour of the tumour.