Factors associated with delay in presentation among patients for oral cancer

A total of 140 cancer patients who met the inclusion criteria were invited to participate in this survey. Among all the retrieved questionnaires, 12 were invalid, leaving 128 (91.43%) included in the final analysis. The general characteristics of participants are presented in Table 1. Most of the patients with oral cancer were men (68.7%). Approximately half of the patients were between 18 and 45 years of age. A total of 75.8% of participants were married. It was found that 40.6% reported monthly income of 1000 to 3000 RMB. Farmers comprised the largest proportion of respondents. Additionally, 43.8% of participants current smoked.

Regarding medical seeking information, 51.6% of participants found their abnormal oral symptoms as a result of experiencing pain, and the largest proportion of the sample reported to the regional center hospital when the symptom occurred. The mean score for oral cancer knowledge on the HOCKS was 10.19 (SD = 2.83). The mean score for coping style on the MCSQ was 45.11 (SD = 6.38). Figure 1 shows the distribution of delay in presentation and demonstrates the positive skew. The duration of patient delay ranged from 0 to more than 5 years. The median duration of delay in presentation was 30 days. Using the cutoff of more than 3 weeks, 78 participants (60.9%) were considered to have experienced prolonged patient delay and 50 participants (39.1%) did not delay in presentation.

Univariate logistic regression revealed that gender, age, education level, monthly income, employment, smoking status, place of residence, the method by which patients discovered their difficulty, oral cancer knowledge and coping style were significantly associated with patient delay in presentation for oral cancer. The results are shown in Table 2. In the multifactor logistic regression, we further found that there was a greater delay among patients who were male, farmers and had a history of smoking (Table 3). Patients who were farmers had a twofold higher risk of delay compared with those who were technicians (Odds ratio [OR] = 2.617; 95% CI: 1.90–3.64). Likewise, patients who had stopped smoking (OR = 3.742; 95% CI: 1.41–8.54) and those who were currently smoking (OR = 4.651; 95% CI: 1.21–9.46) had a higher risk of delay compared with the patients who had never smoked. Female patients had a lower risk of delay compared with male patients (OR = 0.044; 95% CI: 0.01–0.84). Patients whose difficulty had been discovered during a physical exam had a much lower risk of delay compared with patients who discovered the disease independently (OR = 0.029; 95% CI: 0.01–0.30). In addition, patients with higher coping style scores (OR = 0.747; 95% CI: 0.47–1.18) and higher oral cancer knowledge scores (OR = 0.886; 95% CI: 0.60–2.01) had a lower risk of delay.

The aim of this study was to explore the factors associated with patient delay in presentation for oral cancer. We found a more than 3 weeks patient delay for 60.9% of oral cancers with potentially malignant oral symptoms, with a median length of delay of one month. This length of time was consistent with the findings of a previous study by Olesen et al. reporting on patients’ delay in seeking treatment in Iran [23]. In contrast, patient delay in seeking treatment for oral cancer symptoms was about 7 to 8 weeks in India [24]. In a study from Canada, the average delay was shown to be 12 weeks [25]. Early recognition is essential for purposes of improving survival rates, preserving oral function and enhancing overall esthetic and psychological outcomes.

It is uncertain whether gender is an associated factor for oral cancer patients’ delay in presentation. One study [26] showed that men demonstrated more delay than women. This result is similar to our conclusion. Paying more attention to oral health and potential lesions in this area for women may explain the greater delay among men. However, in another related study [27] investigating the association between delay in seeking treatment and psychological factors among 277 patients with cancer of the head and neck, the evidence indicated that gender was not related to patient delay in seeking medical help. Men are considered to be at high risk for oral cancer, and most of the patients in our study were men, so there may need to be more research conducted with women, in order to draw a conclusion about the impact of gender on delay time.

There seems to be an inseparable relationship between occupation and economic conditions. The economic status of people with higher social status is relatively better. The relationship between occupation and patient delay behavior warrants further investigation because this has been verified to be an influential factor in the study of patient delay [13,28]. Lower occupational social class was found by Llewellyn et al. [16] to be associated with longer patient delay, with higher morbidity and mortality in the more deprived people. Scott et al. [28] found that impoverished patients were less likely to find malignant lesions in the early stages, which further supports Llewellyn et al.’s[16] finding that patients with lower socioeconomic status were more likely to delay in seeking treatment help. The result of our study can be explained by the fact that the patient sample comes from the economically deprived population in the city of Changchun rather than the more prosperous coastal cities of China. After noticing the early symptoms, patients may attempt self-treatment due to economic constraints, which could account for their delay in seeking professional medical attention.

A total of 100 patients with squamous cell carcinoma of the oral cavity were examined in one study [29]. The result found that patient delay in seeking treatment was related to whether the patients were heavy smokers. Similarly, we also found in our study that risk of delay for patients who smoked either currently or in the past was much higher than for patients who had never smoked. However, another study [9] found that delay was inversely related to the amount of tobacco that patients smoked. The results in that case suggested that risk of delay was higher for those who smoked less tobacco. One reason for this latter finding may be that nonsmokers or light smokers realize their own low risk, causing them to mislabel symptoms as insignificant, thus leading to a delay in seeking professional advice. The relationship between delay and the amount of tobacco that patients smoked will be examined in our further study.

The method by which patients discovered their difficulty was associated with patient delay in presentation in our study. Regular physical examinations could significantly reduce patient delay in seeking treatment when problems arise. One study [9] investigated patients of an oral medicine clinic in Australia. Most participants reported that experiencing an ulcer, as a common initial symptom, had caused them to actively seek help. In contrast, the method by which patients discovered their symptoms was not found to have an association with patient delay in another study [16]. This could be because some of the early symptoms of oral cancer, such as ulcers or growths, are not uncommon in the oral cavity [9]. Alternatively, it may also be the case that the patients understand very little about the clinical manifestations of oral cancer [30]. Therefore, early and more widespread adoption of oral cavity screening and overall examinations for head cancer, have the potential to detect asymptomatic cancers at early stages and prompt those who show symptoms to consult a health care professional [31].

Medical seeking and sociodemographic variables can only explain patient delay in part. There was a general lack of knowledge about oral cancer among the participants in the current study, which proved the delay was associated with a lack of understanding of the symptoms of oral carcinoma and its risk factors. Other research [32] has also shown that patients with more accurate knowledge of oral cancer were unlikely to delay seeking help. Oral cancer knowledge is associated with a greater likelihood of seeking out oral cancer screening, thus promoting early detection. One qualitative study [9], which investigated oral cancer patients’ perceptions of their initial symptoms, found that approximately half of the participants interpreted common symptoms such as a pain or nonhealing ulcer, as something minor and rarely gave thought as to whether it might be oral cancer. One possible explanation, in the case of our study, is that most of the respondents had a low level of education and a lack of knowledge of early oral cancer symptoms, which led them to delay in seeking treatment. Thus, the best way to get patients to self-refer earlier may be through strengthening public education to improve knowledge of oral disease.

Our research also demonstrated that coping style was related to patient delay in seeking care. The nature of this relationship will need to be further validated in future research, which we are planning to conduct. Research by Tromp et al. [27] was supportive of this premise, as their study demonstrated that patient delay was positively related to avoidance coping style, and patients who postponed medical seeking for longer periods of time made less use of the active coping style. This is in agreement with other research as well, as Lauver and Tak [33] found that patient delay was associated with avoidance coping style and patients who postponed the medical consultation for more than one month made less effort in seeking medical support. Thus, it seems essential to ensure that interventions be directed at decreasing negative coping styles and improving positive coping styles for oral cancer patients.

Several limitations of this study should be kept in mind when interpreting the current findings. First, this study used a cross-sectional design rather than a longitudinal one, a factor which prevents us from drawing any causal conclusions. Second, our study recruited convenience samples with oral cancer from only certain regions in China and, therefore, the findings cannot be used to make generalizations to other developed areas and countries. Third, this study used questionnaires to ask patients to recall early symptoms and when they appeared. The accuracy of this information is limited by patient recall and by the level of significance they attached to these symptoms.

Overall, our study demonstrates that lack of regular screening is associated with delay in presentation among oral cancer patients in our population. Similarly, negative coping style and lack of knowledge about oral cancer also seem to contribute toward this delay. These identified factors associated with it may be used in designing an intervention program for reducing patient delay. Specifically, the most feasible way to better inform the public about early symptoms of oral cancer, may be through regular screening of the oral mucosa with patients at greatest risk.

XY Zhang and LJ Bian were involved in the conception and design of the study, DL Liu, HM Dong and BY Zhang were involved in the drafting of the paper or revising it critically for intellectual content; Y Zhang and XY Zhang were involved in the analysis and interpretation of the data; YX Li and XL Wang were involved and in the final approval of the version to be published. All authors agree to be accountable for all aspects of the work.

We thank the authors of all of the included studies.

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

The authors state that they have obtained appropriate institutional review board approval or have followed the principles outlined in the Declaration of Helsinki for all human or animal experimental investigations. In addition, for investigations involving human subjects, informed consent has been obtained from the participants involved.