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Reviewed research
Authors Oberoi DV, Jiwa M, McManus A, et al.
Review Date May 2016
Citation European Journal of Cancer Care 2016; 25: 27-37
Background
Colorectal cancer (CRC) is one the of most common cancers worldwide, and Australia and New Zealand together have the highest incidence and mortality rate. Men are at greater risk of CRC and typically have a worse prognosis than women. Previous research has demonstrated a lower awareness of the risk factors for CRC among men and that they are also less likely to seek medical attention for symptoms. Few CRC studies have been conducted with participants from Australia or have considered patients’ experiences of symptoms prior to diagnosis.
Aim
This study aimed to identify the potential reasons for delay between the onset of symptoms and the diagnosis of CRC in a group of Australian men.
Methods
The development of the interview schedule and data analysis were guided by Andersen’s Model of Total Patient Delay. This model has four stages dedicated to patient-related factors (appraisal, illness, behavioural, and scheduling delays) and one to healthcare-related factors (treatment delay).
Western Australian men who had been diagnosed with CRC in the previous 3 months were invited to participate in the study (no further recruitment details are provided). Purposive sampling was used to include a variety of ages, social backgrounds and cancer stage at diagnosis.
Semi-structured interviews were conducted February-July 2013. Participants were first asked to talk about their experiences of lower bowel symptoms from time of onset to CRC diagnosis; questions based on the theoretical model used were then asked. Transcription and analysis took place after each interview. Participants had the opportunity to review their interview transcript for accuracy.
Results
Twenty men volunteered to participate in the study and interviews ranged from 25-35 minutes. The mean age of participants was 62.2 years (range: 27-87). The majority of men had completed high school and two were tertiary educated. The mean time between symptom onset and first medical consultation was 7.4 months (median: 5.5).
APPRAISAL DELAY
Participants’ responses to symptoms: Most reported one or more symptoms prior to diagnosis including diarrhoea, rectal bleeding, abdominal pain and unintentional weight loss; two men had no symptoms. The nature and severity of symptoms (e.g. intermittent bleeding or bowel habit changes versus major episode of bleeding or bleeding with pain) lengthened or shortened the delay in seeking care. Men often ignored the symptoms when they first appeared but were prompted to seek care when they persisted, worsened, or new symptoms appeared.
Misinterpreting the symptoms: Participants often attributed their symptoms to benign ailments such as haemorrhoids or poor eating habits. Some purchased over-the-counter products for these conditions which relieved symptoms but increased diagnosis delay. A few men believed their symptoms were due to work-related issues (e.g. lifting heavy weight), previous medical treatment, or side-effects of medications.
ILLNESS DELAY
Disclosure of symptoms to significant others: Most men discussed their symptoms and whether they warranted a GP consult with their partner and some discussed it with their mother, friend at work, or cousin. Participants typically initiated these conversations after the symptoms had persisted for several weeks or months. The majority were encouraged to seek care. Those who did not discuss their symptoms did so due to not having a partner, wishing to maintain privacy, and living alone.
Fear of cancer: The fear of having cancer prompted men with a family history of CRC to seek care while one man (without a family history) stated that this fear prevented him from seeking care.
BEHAVIOURAL DELAY
Delay to schedule an appointment with the GP: Participants reported several delays after deciding to seek medical care. These included social and professional commitments and the belief that symptoms may not actually warrant medical help or that they may still clear up spontaneously. Two participants mentioned that previous poor experiences with the healthcare system further delayed their seeking care.
SCHEDULING AND TREATMENT DELAY
Delay in referral for colonoscopy: Most participants reported their GPs as performing a digital rectal examination and referring them on for a colonoscopy based on their age, symptoms and/or family history. However, five participants reported their GP as advising them not to worry about their symptoms.
Waiting times for colonoscopy: Even when urgent referrals were made, some men reported long waiting times to see a surgeon in the public health system. One man with private health insurance had a colonoscopy within 2 days of referral whereas the remaining men waited 1 week to 6 months for this procedure.
Conclusion
Diagnosis delay for CRC in men was explained by men’s inability to attribute symptoms to a condition warranting medical care and procrastination in seeking care even when it was believed to be beneficial. Delays were further compounded by GP misdiagnosis and long waiting times for colonoscopy. The findings of this study support the need for development of interventions targeted at men and GPs to reduce diagnostic delays for CRC at the primary care level.
Points to Note
- Colorectal cancer (CRC) is a common cancer with a high mortality rate, particularly among men. This study considered the potential reasons for delay in the period of time between onset of symptoms and diagnosis of CRC for Australian men.
- Twenty men with a recent diagnosis of CRC were interviewed about their experiences of lower abdominal symptoms and associated care received prior to CRC diagnosis. A theoretical model that largely considers patient-related factors (as opposed to healthcare-related factors) was used to guide data collection and analysis.
- Diagnosis delay was explained by men’s inability to attribute symptoms to a condition that warranted medical care and also to procrastination in seeking such care once it was believed to be necessary. Misdiagnosis by GPs and long waiting times for colonoscopy further compounded the delay experienced by men.
- The theoretical model used focused primarily on patient-related delay which is likely to have presented a skewed picture of men’s experiences of diagnosis delay. Further, the model fails to take into account the non-linear process of men’s help-seeking experience for CRC.
- This study did not consider potential delay between colonoscopy and first treatment, an important time period for satisfactory CRC patient outcomes.
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