Rozniatowski Olivier
Page 1
Psychosocial factors
involved in delayed
consultation in
head and neck
cancer patients
Rozniatowski
Olivier
Psycho-oncology Unit, Centre Oscar Lambret, 59020, Lille, France
keywords : Head and neck cancer,
oral cavity,
delay in consultation, anxiety, depression,
social isolation, spouse, partner
Abstract : Background. In the north of France, a delay in primary consultation has been noted among head
and
neck cancer patients. This group is often correlated with lower socio-economic status and a lack of medical
information. Therefore, the
choice to seek consultation is often influenced by symptoms such as pain and change
in the size of tumors in the neck.
Aims.
We studied this delay in seeking consultation, focusing on psychosocial variables such as professional and
social background, the involvement of a spouse/partner, and the
presence of anxiety and depression.
Methods.
Two rating
scales
were
administered to
50 patients with large
tumors (T3/T4) compared
with 50
patients with small
tumors (T1/T2):
(i) a 17
item questionnaire assessing socio-demographic data, presenting
symptoms, factors generating the consultation, and reasons for delay ; (ii) the HADS : (The Hospital Anxiety and
Depression Scale).
Rozniatowski Olivier
Page 2
Results. Both groups were predominantly
male and working-class. Significant differences were observed in time
since symptom onset, and conscious delay in seeking medical attention. The sample involving large tumors was
characterized by lower involvement of a spouse/partner, conscious delay prior to first consultation, greater social
isolation, fewer medical visits,
and lower HADS
anxiety
scores.
The sample
with small tumors
sought
consultation sooner and was characterized
by
greater involvement of a spouse/partner, correlated with significant
anxiety. Depression was not
a factor influencing delay within either group.
Conclusions.
The
interpersonal
relationship with a spouse/partner seemed to be essential in the dynamics
surrounding consultation. Anxiety, rather than socioeconomic status, was a discriminating factor in the delay in
seeking consultation.
Faced with the onset of head and neck cancer symptoms, patients do not always behave in an
appropriately
responsive manner. Many patients don’t react objectively to their symptoms by
seeking a medical consultation.
In the north
of France, a delay in
the
time
to first consultation has been observed among
head
and neck
cancer patients1a. The consultation is often prompted by intolerable pain or
by
tumor’s size causing a
major functional disturbance.
In this region of France,
epidemiological data1b show a tremendously high
incidence of
cancer,
especially for this type of cancer.
For
head and neck cancer, the annual incidence per 100,000 inhabitants is 16 for the USA; 18
for the EEC;
37 for France and 39 for the north of France region
alone1b , this
latter
demonstrating
the highest incidence in the world.
Relatively little is known about the reasons why, in the north of France, there is such a delay
in seeking
medical care for these tumors.
Rozniatowski Olivier
Page 3
Several studies have examined factors that might explain the delay, though none have studied
these findings specifically with regard to our region. These factors include:
Socioeconomic
conditions2 :
patients belonging to higher social classes may show less delay
in seeking consultation3.
The presence of a partner may
also play a role in seeking early consultation4,5
As a defense mechanism, denial may help with coping in the early stages by negation of the disease and its symptoms6.
Lastly, the existence of an underlying psychopathology, such as a depressive disorder, anxiety disorder or addiction may contribute to
the delay7. For instance, the excessive consumption of
alcohol and tobacco
in this kind of population has classically been understood as a self-
destructive behavior, one which may correlate with delay in seeking help.
Many
other studies8,9 have shown a correlation with poor socioeconomic conditions, but only
in
underdeveloped countries.
Thus,
the aim of this study was two-fold :1) to quantify the psycho-social characteristics of
these patients and
2) to
better define the reasons
that
lead this type of
patient to seek
consultation belatedly, in the face of sizeable lesions developing over the course of weeks or
months.
Patients and methods
Our
sample was composed of 100
head
and neck cancer patients, specifically those with
oropharyngeal and
oral cavity tumors.
Nasopharyngeal
cancers were
excluded
due to
their
Rozniatowski Olivier
Page 4
low incidence and their specific epidemiology
(involvement of viral infections,
genetic
predisposition).
Laryngeal and hypopharyngeal cancers were also excluded since they induce impairment in
phonation (spontaneously, or due to tracheotomy or tracheostomy) which would not permit an
interview under the
same conditions
as that of other patients.
Moreover,
this type of deep
lesion
could generate a selection bias, since the first clinical signs are not easily discovered by
patients themselves or by a general practitioner.
Furthermore,
due to their
communication
impairment, all patients with laryngectomy or tracheotomy were also excluded
from the
study.
Data collection was performed by a psychologist using a semi-structured interview. Patients
were asked to speak in a narrative fashion about the onset of their illness.
At the Oscar Lambret Center, between September 2000 and July 2002, one hundred patients
with head and neck
cancers were included and divided into two groups :
Fifty patients with large lesions: patients who started treatment at an advanced stage of the
disease (Stage T3/T4 from the UICC classification11).
Fifty patients with smaller
lesions, who constituted the control group: patients
who
started
treatment at an earlier stage of the disease (stage T1/T2 from the UICC classification).
REFERENCES
1a. Le Cancer des Voies Aéro-Digestives Supérieures dans
le
Nord Pas-de-Calais. Analyse
descriptive de la prise
en
charge. Rapport technique réalisé par l’URMEL et l’URCAM. PRS
“Challenge” 2001; 3:39.
1b. Le Cancer des Voies Aéro-Digestives Supérieures dans
le
Nord Pas-de-Calais. Analyse
descriptive de la prise
en
charge Rapport technique réalisé par l’URMEL et l’URCAM. PRS
“Challenge” ; 2001; 3:3-4.
2. Oji
C. Late presentation of orofacial tumours. J Craniomaxillofac Surg 1999; 27:
94-99.
3. Hackett TP,
Cassem NH, Raker JW. Patient delay in Cancer. N Engl J Med 1973; 289 :14-20.
4. Kreitler S, Chaitchik S, Rapoport Y, Algor R.
Psychosocial effects of level of information
and
severity of disease on head and neck cancer patients. J Cancer Educ 1995; 10:144-154.
5. Humpris GM, Ireland RS, Field EA. Randomised trial of the psychological effect of information
about oral cancer in primary care settings. Oral Oncol 2001; 37: 548-552.
6. Worden JW, Weisman AD. « Do
cancer patients really want counseling ? », Gen
Hosp Psychiatry
1980;
2 :100-103.
7. Kugaya A, Akechi T, Okuyama T, Nakano T, Mikami I, Okamura H, Uchitomi Y. Prevalence,
predictive factors and screening
for psychologic distress
in patients with newly diagnosed
head
and neck cancer. Cancer 2000 ; 88 : 2817-2823.
8. Kerdpon D, Sriplung H. Factors related to delay in diagnosis of oral squamous cell carcinoma in
southern Thailand.Oral Oncol. 2001;37(2):127-31.
9. Oburra HO.
Late presentation of
laryngeal and
nasopharyngeal
cancer
in Kenyatta National
Hospital. East Afr
Med
J. 1998;75(4):223-226.
10. Le cancer dans le
Nord Pas de Calais, incidence 1998. Données
issues de l’assurance maladie,
analyse complémentaire. 2001;2: 17.
Rozniatowski Olivier
Page 12
11. American Joint Committee on Cancer. Manual for staging of cancer. Philadelphia : JB Lippincott,
1988.
12. Zigmond AS, Snaith RP. The hospital
anxiety and depression scale. Acta Psychiatr Scand 1983;
67:361-370.
13. Razavi D, Delvaux N, Farvacques C, Robaye E. Validation de la version française du HADS dans
une population de patients cancéreux hospitalisés. Rev Psychol Appl
1989; 39(4):295-308.
14. Samet JM, Hunt WC, Lerchen ML, Goodwin JS. Delay
in seeking care for cancer symptoms: a
population-based study
of
elderly New Mexicans. J Natl Cancer Inst. 1988;80(6):432-438.
15. Rubright WC, Hoffman HT, Lynch CF, Kohout FJ, Robinson RA, Graham S, Funk G, McCulloch
T. Risk factors for advanced-stage oral cavity cancer. Arch Otolaryngol Head Neck Surg 1996
Jun ;122(6) : 621-626.
16. Kowalski
LP, Carvalho AL. Influence of time delay and
clinical
upstaging
in the prognosis
of
head and neck cancer.
Oral Oncol 2001;37(1):94-98.
17. Kumar S, Heller RF, Pandey
U, Tewari V, Bala N, Oanh
KT. Delay in
presentation of oral
cancer:
a
multifactor analytical study.Natl Med J India. 2001;14(1):13-17.