Prognostic Significance of Diagnostic Delay and Deprivation in the Management of Upper Gastrointestinal Cancer

Special Article – Gastric Cancer

Gastrointest Cancer Res Ther. 2017; 2(2): 1021.

Prognostic Significance of Diagnostic Delay and Deprivation in the Management of Upper Gastrointestinal Cancer

Blake PA¹*, Karran AL¹, Chan DSY¹, Roberts SA² and Lewis WG¹

1¹South East Wales Upper GI Cancer Network, University Hospital of Wales, Cardiff, United Kingdom

²Department of Radiology, University Hospital of Wales, Cardiff, United Kingdom

*Corresponding author: Mr Blake PA, Department of Upper GI and General Surgery, University Hospital of Wales, Heath Park, Cardiff, UK CF14 4XW, United Kingdom

Received: April 30, 2017; Accepted: May 29, 2017; Published: June 05, 2017


To examine the time taken to diagnose upper gastrointestinal (UGI) cancer, identify sources of delay, and assess its prognostic significance.

Methods: Prospective study of 150 consecutive upper GI cancer patients presenting to a UK cancer network. Outcome measures were times from onset of symptoms to histological diagnosis, radiological-staging steps, decision to treatment, and whether potentially curative therapy was possible.

Results: Total delay consisted of the following components: patient delay (median 12 weeks, 76%); practitioner delay (median 1 day, 1%) and hospital delay (median 25 days, 23%). Overall median delay from onset of symptoms to diagnosis was 15.5 (1-142) weeks. On multivariate analysis the factors influencing patient delay were; gender (HR 1.463, 95% CI 1.038-2.063, p=0.030) and overall deprivation rank (HR 1.000, 95% CI 1.000-1.001, p=0.005). Urgent Suspected Cancer referrals consisted of 94 patients (63%) and were more likely to receive curative treatment (43%) than the 56 patients (37%) referred via Non Urgent Suspected Cancer pathway (25%, p=0.017). Survival was significantly related to overall delay (R=0.210, p=0.010), patients with the shortest delays survived a median 6 (0.25 to 30) months compared with patients with the longest delays who survived for a median 12.5 (0.5 to 32) months.

Conclusions: Patient delay accounted for over three quarters of total delay, and deprivation was an important and independent factor in this regard. Improved public awareness and doctor education, with lower thresholds for referral in deprived geographical areas allied to streamlined diagnostic pathways, are required if earlier diagnosis of UGI cancer is to be achieved.

Keywords: Diagnostic delay; Oesophago-gastric cancer; Deprivation; Outcome


The most important prognostic factor in patients diagnosed with oesophageal or gastric cancer is the stage of disease at presentation, yet despite advances in information technology and therapies incurable metastatic disease is still diagnosed in as many as 50% of patients at first presentation [1]. In the absence of a national UK screening programme, and given that tumour doubling time can be as little as 2 months for advanced gastric cancer [2,3] and less than 7 months for oesophageal cancer [4] avoidable delay may potentially allow tumours to upstage significantly.

British Society of Gastroenterology (BSG) guidelines recommend that all patients over 55 years of age with recent onset dyspepsia, and all patients with alarm symptoms suggestive of UGI cancer irrespective of age, should be referred for rapid access endoscopy and biopsy [5]. Moreover, the UK Department of Health has specified that urgent investigations be performed within two weeks of referral [6]. Nevertheless, the potential for delay along the patient’s journey are many, and delay may arise at any of three junctures from the initial onset of symptoms to diagnosis; the interval between first noticing symptoms and first consulting a doctor (patient delay); the interval between primary consultation and the subsequent time taken for referral for further investigations (practitioner delay); and finally the time between receipt of referral and diagnosis (hospital delay) [7].

Deprivation is a broad concept which includes limited access to the opportunities and resources which society might expect such as good health, a clean and safe living environment, and protection from crime. Eight types of deprivation, or domains, have been described, including; employment, income, education, health, community, geographical access to services, housing, and physical environment [8]. Multiple deprivations refer to the different types that might occur, and represents a far more profound notion than poverty alone. According to the Welsh Government Cancer Delivery Plan Annual Report (2014) [9] considerable differences remain in cancer incidence, mortality and survival between the least and most deprived geographical areas of the country whereby there is a 21% higher incidence in the most deprived areas compared with the least. Furthermore, one year survival rate is 17% lower in the most deprived areas compared with the least deprived areas, and five year survival difference is even greater, with 28% fewer patients in the most deprived areas surviving to 5 years compared with patients in the least deprived areas [9].

Staging protocols for oesophago-gastric cancer are now complex including endoscopy, CT, CT PET and Endoscopic Ultrasonography (EUS), all of which carry their own potential for further delay. As prognosis for patients diagnosed with UGI cancer is often poor, the potential benefit from understanding and addressing reversible factors is substantial. The aim of this study is to identify the source and magnitude of such delays, determine the prognostic significance, and examine whether delays are related to deprivation.

Materials and Methods

Data was collected on 150 consecutive patients [median age 70 years (range 26 to 95), 96 male, 54 female, 102 oesophageal, 48 gastric cancer, 125 adenocarcinoma (ACA), 25 squamous cell carcinoma (SCC), diagnosed between 1st August 2012 and 31st July 2013 within 2 South East Wales Health Boards (Aneurin Bevan and Cardiff and Vale). All patients were managed by the South East Wales UGI Cancer network multidisciplinary team (MDT).

The time interval (weeks) between the patient first noticing symptoms and presenting to their general practitioner (GP) was recorded according to the patient’s personal recollection of events and cross-referenced with the GP urgent suspected cancer (USC) referral letter. For emergency admissions the delay between first noticing a symptom and presentation to hospital was recorded. Practitioner delays (days) were recorded from the Welsh National Cancer Network Information System (CANISC) database and patient notes. Hospital delays were also recorded contemporaneously from CANISC. For hospital delays, intervals were recorded between date of GP referral to the date of upper gastrointestinal endoscopy (OGD), to date of CT (days), from date of OGD to CT (days), from CT to EUS (weeks), from CT to CT PET (weeks), from referral to diagnosis (days), from referral to the decision to treat date at the regional MDT (weeks), and from the decision to treat date to the commencement of treatment (weeks). The overall delay between initial onset of symptoms and the date a decision to treat was made was also recorded. Date of diagnosis was the day on which a histological diagnosis of malignancy was confirmed. In the case of patients who did not undergo OGD date of diagnosis was recorded as the day the patient underwent radiological imaging.

Deprivation rankings were designated for each patient using the Welsh Index of Multiple Deprivation (WIMD) 2011, [8]. This index gives the official measure of multiple deprivation for every postcode in Wales and is based on eight described forms of deprivation including employment, income, education, health, community, geographical access to services, housing, and physical environment. The country is divided into 1,896 areas of approximately 1,500 people with the most deprived geographical area ranked 1 and the least deprived area ranked 1,896. The WIMD for all areas was also sub-classified into equally sized socio-economic quintiles; the most deprived group was labelled quintile 1, and the least deprived quintile 5. Health deprivation (HD) was also examined, the indicators for which are cancer incidence, all-cause death rate, percentage of live single births <2.5kg, and the number of inhabitants with limiting long-term illness per 100,000 of the population [8]. HD was similarly sub-classified into equally sized quintiles.

Staging investigations

Patients deemed to have potentially curable tumours underwent diagnostic gastroscopy with histopathological confirmation of oesophageal or gastric cancer and computed tomography (CT) of the thorax and upper abdomen. Patients selected for radical treatment also underwent EUS, CT Positron Emission Tomography (CT-PET) and laparoscopy, if appropriate. Tumours were staged according to the unified TNM classification of UGI cancer, edition 7 [10].

Multidisciplinary management

Patients were initially discussed at one of three local multidisciplinary team (MDT) meetings and if deemed potentially curative they were then discussed at the regional South East Wales UGI MDT meeting. Patients were selected for appropriate radical treatment based on histopathological stage, co-morbidity, the technical feasibility of surgery and patient choice according to an algorithm described previously [11]. Patients unsuitable or who declined radical therapy were offered specialist palliative care.

Statistical analysis

Statistical analysis appropriate for non-parametric data was used. Grouped data were presented as median (range), and quintiles were grouped to allow Cox regression analysis. Bivariate correlations were calculated using Spearman`s correlation test. Differences were deemed statistically significant when p<0.05. Data analysis was carried out with the Statistical Package for Social Sciences (SPSS) version 20 package (IBM Corporation, New York).


Patient delay

The median time interval between patients first experiencing symptoms and initial presentation to a medical practitioner was 12 (1 -104) weeks and accounted for 76% of the delay from initial onset of symptoms until the decision to treat date. Patient delay correlated with gender [females 13 (2-104) weeks compared with males 8 (1-78) weeks (R =-0.179, p=0.030)], level of deprivation (R=-0.214, p=0.009), and health deprivation (R=-0.214, p=0.009). When analysed by quintile, the median delay for patients in the most deprived quintile was 13 (2-78) weeks compared with 8 (1-26) weeks for those in the least deprived quintile (R=-0.210, p=0.010). With regard to HD, the median delay for patients in the most deprived HD quintile was 15 (4-78) weeks compared with 8 (1-26) weeks for those in the least deprived quintile (R=-0.210, p=0.010) (Table 1).