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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 12  |  Issue : 1  |  Page : 75-78

Association of socioeconomic risk factor with patients delay in presentation of oral squamous cell carcinoma


Department of Oral Medicine and Radiology, Sharad Pawar Dental College and Hospital, Datta Meghe Institute of Medical Sciences (Deemed University), Wardha, Maharashtra, India

Date of Web Publication25-Jul-2017

Correspondence Address:
Vidya K Lohe
Department of Oral Medicine and Radiology, Sharad Pawar Dental College and Hospital, Datta Meghe Institute of Medical Sciences (Deemed University) Sawangi (M), Wardha, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_29_17

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  Abstract 

Background: Delayed reporting is a common problem in patients with low socioeconomic group and may be responsible for advanced stage disease. Aim: To evaluate association of socioeconomic risk factor with patients delay in presentation of Oral Squamous Cell Carcinoma (OSCC). Material and Methods: Thorough case history of 120 histopathologically confirmed OSCC patients was taken and were categorized according to TNM staging. Their SES was assessed by Aggarwal OP et al (2005) scale. Patients delay in presentation was calculated by measuring the time between the onset of the first symptoms of OSCC and the first consultation with primary health care provider. Association of socioeconomic status (SES) with patients delay in presentation was sought. Observations and Results: Out of 120 OSCC patients, there were 04 (3.33%) patients from stage II, 31(25.83%) from stage III, 85 (70.83%) from stage IV. Thirteen (10.80%) patients reported within 3 months of onset of the first symptoms, 14 (11.66%) patients reported upto 3 months, 72 (60.00%) reported between 3-6 months, 20 (16.66%) between 6-9 months and 14 (11.66%) between 9-12 months. Association of clinical staging and patient delay was sought by subjecting to chi square test, and the x2 value was 43.80, P = 0.0001, suggesting statistically significant difference. An association of clinical staging, SES and period of patient's first presentation was also carried out and data subjected to chi square test which was statistically significant in all the subgroups of SES. Conclusion: From this study, it can be concluded that there is significant association of socioeconomic status with patients delay in presentation of oral squamous cell carcinoma

Keywords: Clinical staging, delay in presentation, oral squamous cell carcinoma, socioeconomic status


How to cite this article:
Lohe VK, Bhowate RR, Sune RV, Mohod SC. Association of socioeconomic risk factor with patients delay in presentation of oral squamous cell carcinoma. J Datta Meghe Inst Med Sci Univ 2017;12:75-8

How to cite this URL:
Lohe VK, Bhowate RR, Sune RV, Mohod SC. Association of socioeconomic risk factor with patients delay in presentation of oral squamous cell carcinoma. J Datta Meghe Inst Med Sci Univ [serial online] 2017 [cited 2019 Jun 26];12:75-8. Available from: http://www.journaldmims.com/text.asp?2017/12/1/75/211587


  Introduction Top


An extended period of patients delay in presentation following the onset of symptoms is hypothesized to provide an important explication for diagnosis at an advanced stage. It is a logical assumption that a cancer's stage at diagnosis is partially the length of time it had been developing before diagnosis as oral cancer is known to increase in size over time. Furthermore, early diagnosis would lessen mortality from oral cancer and improve the quality of life. An increased clinical suspicion and determinants of patients delay may help accomplish earlier diagnosis by minimizing the causes for delay.

Oral cancer is easily detected by perceiving a lesion in the oral cavity; however, 60% of patients with oral cancer have advanced cancer and may have delay in seeking medical advice.[1] The silent nature of oral lesion of oral cancer and delay in diagnosis are thought to be responsible for this high incidence of advanced stage oral cancer.[2],[3]

According to Gómez et al.,[4] the probability that patients with delayed diagnosis present at an advanced stage tumor at the time of diagnosis is approximately 30% higher than for nondelayed diagnosis patients. Those patients presenting with advanced stage cancers have a less chance of survival too. There are number of reasons why people do not visit clinicians soon after noticing symptoms. One of which is the financial barrier; moreover, patients may have inadequate or incorrect knowledge to appropriately interpret the relevance of their symptoms to malignancy or possibly fail to seek help due to the fear of cancer or lack of faith in medical treatment. This may be called as the “patient delay” or “diagnostic delay.”[5]

An understanding of the reasons for late-stage diagnosis of head and neck cancer could assist in the design of interventions aimed at reducing the frequency of these disastrous events. Besides, it can help health authorities to implement effective programs to prevent oral cancer. To modify patients health behavior, thus improving their vital prognosis and quality of life as well as reducing social inequalities regarding health, it seems essential to take into account not only patients representations concerning health but also the social, emotional, and contextual determinants of their decisions and behavior.[5] Therefore, the present study was undertaken “to evaluate association of socioeconomic risk factor with patients delay in presentation of oral squamous cell carcinoma (OSCC).”


  Patients and Methods Top


One hundred and twenty patients with histopathologically confirmed diagnosis of OSCC from rural area were included from the outpatient Department of Oral Medicine and Radiology for the study. Exclusion criteria were that of malignancies other than OSCC, patients from urban area, and medically compromised patients.

Methodology

This cross-sectional study was carried out in the Department of Oral Medicine and Radiology, during 2013–2016. Patients who met the inclusion criteria were randomly selected and interviewed. After taking a written informed consent from the patient, they were briefed about the study and a thorough case history was taken including demographic data, adverse habit, and history about other risk factors. All the patients were enquired about the length of time, from the time at which the patient first became aware of the symptoms to his or her visit to a primary care clinician. A complete clinical examination of all the 120 OSCC patients was carried out, and the cases were clinically categorized according to clinical tumor, node, metastasis (TNM) staging into Stage I, II, III, and IV. Patients' delay in presentation was measured by time between the onset of the first symptoms of cancer and the first consultation with primary health-care provider. After that, the patients were interviewed and subjected to Aggarwal et al.[6] instrument containing 22 questions (items) for knowing their socioeconomic status (SES), and accordingly, categorization of SES was done into high, upper middle, lower middle, poor, very poor and its association with patients delay in presentation was sought. The data obtained were subjected to statistical analysis.


  Observations and Results Top


Of 120 OSCC patients, there were 4 (3.33%) patients from Stage II, 31 (25.83%) from Stage III, 85 (70.83%) from Stage IV. Thirteen (10.80%) patients reported within 3 months of onset of the first symptoms, 14 (11.66%) patients reported up to 3 months, 72 (60.00%) reported between 3 and 6 months, 20 (16.66%) between 6 and 9 months, and 14 (11.66%) between 9 and 12 months [Table 1]. Association of clinical staging and patient delay was sought by subjecting to Chi-square test, and the χ2 = 43.80, P= 0.0001, suggesting statistically significant difference [Table 2]. An association of clinical staging, SES, and period of patient's first presentation was also carried out and data subjected to Chi-square test which was statistically significant in all the subgroups of SES [Table 3].
Table 1: Distribution of 120 oral squamous cell carcinoma subjects according to duration of patients delay

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Table 2: Association of clinical staging with patient delay

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Table 3: Association of primary delay with clinical staging and socioeconomic status

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  Discussion Top


Detecting OSCC at an early stage is the most effective means of improving survival and reducing morbidity from this disease, and yet, a significant proportion of patients delay seeking help after self-discovery of symptoms. To avoid such complications from arising, there is a need to study the factors that influence delay in treatment seeking among OSCC patients.[7]

In the present study, average age of OSCC patient was 51.24 years. Ninety-four (78.33%) patients were males and 26 (21.66%) were females. The high percentage of cases among males may be due to high prevalence of tobacco consumption habits among males. The patients with early stage cancer frequently manifest minimal physical findings and symptoms, thus resulting in delayed diagnosis and poor survival in many patients. The precancerous lesions are altered epithelial lesions, which have an increased likelihood of progressing to OSCC.[8] In the present study, of 120 OSCC patients, 32 (26.66%) also had oral precancer. Gupta PC et al.[9] in 1989 studied that in high incidence areas, majority of oral cancers arise from long-standing premalignant lesions.

In this study, of 120 histopathologically confirmed OSCC patients, there was no patient from high socioeconomic group, 15 (12.05%) patients were from upper middle, 38 (31.66%) from lower middle, 67 (55.00%) from poor, and none was from very poor SES. The data obtained were subjected to Chi-square test and the “P” value was statistically significant implying that along with other confounding factors, SES can also be considered as a potential risk factor in OSCC. Rooban et al.[10] in 2012 also found that tobacco was used more among slum dwellers ultimately predisposing to OSCC.

The American Joint Committee on cancer in 2002 adopted the TNM classification system for clinical staging of oral cancer.[11] The prognosis for a given tumor is closely related to its clinical stage. In the present study, of 120 OSCC patients, there was no patient from Stage I, 4 (3.33%) patients were from Stage II, 31 (25.83%) from Stage III, and 85 (70.83%) from Stage IV. Association of clinical staging and SES of patient was sought and data obtained were subjected to Chi-square test which was statistically significant. The data on OSCC are still intimidating; the majority of cases are identified late and in advanced clinical stage (i.e., III or IV).[12] AJCC Cancer Staging Manual [11] also identified OSCC at advanced stages with approximately two-thirds of OSCC diagnosed at Stage III and IV.[13] Warnakulasuriya et al. in 1999[14] reported that lack of awareness among the public about oral cancer and the associated risk factors are the primary reasons for delayed presentation of oral cancer.

Association of clinical staging and period of patients' first presentation was carried out and the data obtained were subjected to Chi-square test which was statistically significant. Association of clinical staging, SES of patients, and period of patient's first presentation was also carried out and was statistically significant. This can be partially attributed to lack of accurate identification of the timing of the onset of symptoms. About 30% of OSCC patients usually wait for more than 3 months before consulting medical/dental professional after self-discovery of signs and symptoms of oral cancer.[15],[16] The longer patient delay is linked to the already known sociodemographic, socioeconomic, socioeducational, sociocultural, and socioprofessional factors. However, recent data suggest that some sociocognitive and emotional determinants may explain patient delay from a complementary point of view.[7] Smith et al. concluded that the most common causes of patient delay are fear, lack of symptom recognition;[17] and the other factors may be financial barrier, patients inadequate or incorrect knowledge to appropriately interpret the relevance of their symptoms to malignancy.[5] The patients usually take self-medications in the false opinion of improving the course of the disease, while substantially increasing the duration of diagnostic delay. This delay is related to the difficulty experienced by patient in perceiving such signs and symptoms as harmful, whereas they are usually disregarded as a minor oral illness, for example, trauma, infective process, disorders related to dentures or other generic, nondangerous dental conditions.[18] Along with tobacco habit as established risk factor, SES can be considered as potential risk factor for OSCC [19] and may be one of the causes of negligence in consulting health-care professional. In the present study also, there were various factors responsible for patients delay in presentation such as poor SES, lack of symptom recognition because of silent nature of oral cancer, patients misinterpretation of symptoms, preexisting ideas, experiences of other people, willingness of patient, wait and see attitude, social responsibilities, and financial problems as well. However, worsening and progression of the symptoms made patients to seek medical consultation.


  Conclusion Top


Efforts to reduce exposure to risk factors alone are unlikely to succeed unless they are supported by measures to improve SES. The education and counseling of patient to improve the awareness about OSCC are vital. Reducing the time between the onset of the first symptoms of oral cancer and the first consultation with a health-care professional is essential to improve the prognosis and quality of life of patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Chintala A, Muttagi S, Agarwal C. Reasons for diagnostic delay and its association with socioeconomic factors in advanced oral cancer patients. J Adv Med Dent Sci Res 2014;2:111-8.  Back to cited text no. 1
    
2.
Scott SE, Grunfeld EA, McGurk M. The idiosyncratic relationship between diagnostic delay and stage of oral squamous cell carcinoma. Oral Oncol 2005;41:396-403.  Back to cited text no. 2
    
3.
Onizawa K, Nishihara K, Yamagata K, Yusa H, Yanagawa T, Yoshida H. Factors associated with diagnostic delay of oral squamous cell carcinoma. Oral Oncol 2003;39:781-8.  Back to cited text no. 3
    
4.
Gómez I, Seoane J, Varela-Centelles P, Diz P, Takkouche B. Is diagnostic delay related to advanced-stage oral cancer? A meta-analysis. Eur J Oral Sci 2009;117:541-6.  Back to cited text no. 4
    
5.
Llewellyn CD, Johnson NW, Warnakulasuriya S. Factors associated with delay in presentation among younger patients with oral cancer. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;97:707-13.  Back to cited text no. 5
    
6.
Aggarwal OP, Bhasin SK, Sharma AK, Chhabra P, Aggarwal K, Rajoura OP. A new instrument (Scale) for measuring the socioeconomic status of a family: Preliminary study. Indian J Community Med 2005;30:111-4.  Back to cited text no. 6
    
7.
Christophe V, Leroy T, Seillier M, Duthilleul C, Julieron M, Clisant S, et al. Determinants of patient delay in doctor consultation in head and neck cancers (Protocol DEREDIA). BMJ Open 2014;4:e005286.  Back to cited text no. 7
    
8.
Speight PM. Update on oral epithelial dysplasia and progression to cancer. Head Neck Pathol 2007;1:61-6.  Back to cited text no. 8
    
9.
Gupta PC, Bhonsle RB, Murti PR, Daftary DK, Mehta FS, Pindborg JJ. An epidemiologic assessment of cancer risk in oral precancerous lesions in India with special reference to nodular leukoplakia. Cancer 1989;63:2247-52.  Back to cited text no. 9
    
10.
Rooban T, Joshua E, Rao UK, Ranganathan K. Prevalence and correlates of tobacco use among urban adult men in India: a comparison of slum dwellers vs non-slum dwellers. Indian J Dent Res 2012;23:31-8.  Back to cited text no. 10
  [Full text]  
11.
Fleming ID. AJCC Cancer Staging Manual. 7th ed. Philadelphia, New York: Springer; 2010.  Back to cited text no. 11
    
12.
Pitiphat W, Diehl SR, Laskaris G, Cartsos V, Douglass CW, Zavras AI. Factors associated with delay in the diagnosis of oral cancer. J Dent Res 2002;81:192-7.  Back to cited text no. 12
    
13.
Güneri P, Epstein JB. Late stage diagnosis of oral cancer: components and possible solutions. Oral Oncol 2014;50:1131-6.  Back to cited text no. 13
    
14.
Warnakulasuriya KA, Harris CK, Scarrott DM, Watt R, Gelbier S, Peters TJ, et al. An alarming lack of public awareness towards oral cancer. Br Dent J 1999;187:319-22.  Back to cited text no. 14
    
15.
Allison P, Locker D, Feine JS. The role of diagnostic delays in the prognosis of oral cancer: A review of the literature. Oral Oncol 1998;34:161-70.  Back to cited text no. 15
    
16.
Scott SE, Grunfeld EA, McGurk M. Patient's delay in oral cancer: A systematic review. Community Dent Oral Epidemiol 2006;34:337-43.  Back to cited text no. 16
    
17.
Smith LK, Pope C, Botha JL. Patients' help-seeking experiences and delay in cancer presentation: a qualitative synthesis. Lancet 2005;366:825-31.  Back to cited text no. 17
    
18.
Rogers SN, Vedpathak SV, Lowe D. Reasons for delayed presentation in oral and oropharyngeal cancer: the patients perspective. Br J Oral Maxillofac Surg 2011;49:349-53.  Back to cited text no. 18
    
19.
Lohe VK, Bhowate RR. Association of socioeconomic risk factor with oral squamous cell carcinoma. JDMIMSU 2016;11:243-6.  Back to cited text no. 19
    



 
 
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  [Table 1], [Table 2], [Table 3]



 

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