Delays to diagnosis and treatment of oesophagogastric cancer and its impact on treatment outcomes

Author: Liana Kumar

Kumar, Liana, 2022 Delays to diagnosis and treatment of oesophagogastric cancer and its impact on treatment outcomes, Flinders University, College of Medicine and Public Health

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Oesophageal and gastric carcinoma are the sixth and second leading cause of cancer-related mortality worldwide respectively. These cancers continue to have overall poor survival rates, partly due to late presentation with already advanced stage disease. Both cancers are frequently associated with a delay to diagnosis.

The aims of this study were to identify delays in diagnosis and treatment of oesophagogastric cancers in Australia, and to determine whether delays impacted outcomes and how these delays can be avoided.

The research methodology was approved by The Southern Adelaide Clinical Human Research Ethics Committee and involved collation of data for oesophagogastric cancer patients who underwent surgery with curative intent at Flinders Medical Centre from 2013 to 2018. Data was extracted from the Upper GI unit database containing patient demographic and procedural information, whilst remaining data around symptoms, dates of each timeframe, and outcomes was obtained via retrospective review of patient case notes and electronic records.

In the present study, most patients had delays to diagnosis and treatment (87.5% and 93% respectively). Most of the delay was in the symptom onset to referral time interval (12.5 weeks compared to 1-3 weeks for all other intervals). Most patients presented with late-stage disease (60%) and died within the first two years following diagnosis (66%).

Both cancers are quite different: oesophageal cancer presents mostly with dysphagia, in men peaking in the 60-69 age group whereas gastric cancer presents more with constitutional symptoms and blood loss. Most patients with oesophageal cancer (76%) had fulfilled the urgent referral criteria compared to only 33% of gastric cancer patients.

Despite dysphagia being included in the current urgent referral criteria, it was significantly associated with delays to diagnosis. GPs referred most patients to a Gastroenterologist for endoscopy (60%) which was associated with significant delays from referral to endoscopy (median of 32 days). Over a quarter of patients were diagnosed via the emergency department route and mostly had gastric cancer (63%) presenting with either blood loss or constitutional symptoms.

Most potentially curable patients with oesophageal and gastric cancer have delays to diagnosis and treatment. Most also presented with late-stage disease and died within the first two years, suggesting an association between delays and adverse outcomes. Delays predominantly occur in the interval from symptom onset to specialist referral and more often in patients with dysphagia despite being a symptom included in the urgent referral criteria. Oesophageal and gastric cancer differ significantly, indicating a need for separate referral guidelines for both cancers.

Recommendations for reduction in delays involve (1) New separate referral criteria for oesophageal and gastric cancer which includes gastrointestinal blood loss (anaemia, haematemesis or melena) and constitutional symptoms (nausea, weight loss or anorexia) for gastric cancer, and dysphagia for oesophageal cancer, (2) Education of GPs about the urgent referral criteria through incorporation into the medical and GP curricula, (3) Improving health literacy around symptoms and risk factors through public campaigning, (4) Increasing endoscopy availability through means of open access endoscopy or nurse endoscopists, and (5) Rapid utilization of barium swallow for initial diagnosis.

Keywords: Oesophageal cancer, gastric cancer, endoscopy, referral guidelines, diagnostic delays

Subject: Surgery thesis

Thesis type: Masters
Completed: 2022
School: College of Medicine and Public Health
Supervisor: Dr Tim Bright