Reasons For Delay In Treatment Research Articles

Sentinel lymph node biopsy before mastectomy and immediate breast reconstruction does not significantly delay surgery in early breast cancer.

Sentinel lymph node biopsy (SLNB) before mastectomy and immediate breast reconstruction (IBR) may help to avoid the negative cosmetic effects of radiotherapy on reconstructed breasts in lymph node-positive patients. Concerns have been raised regarding possible delays whilst awaiting the SLNB result prior to definitive surgery, which needs to be performed within 31 days of cancer diagnosis. The aim was to investigate whether initial SLNB delays mastectomy and IBR. All patients who had IBR between January 2005 and 2007 were reviewed retrospectively. Before October 2005 axillary staging was performed simultaneously with mastectomy and IBR (Group I). After October 2005, SLNB was performed as an initial procedure and patients with positive SLNB were only offered a temporary tissue expander to be replaced by autogenous reconstruction after completing the cancer treatment (Group II). Date of diagnosis and waiting times were recorded and the two groups were compared. Different reasons for delays in treatment were studied. One hundred and thirty-nine IBR (123 patients) were included in the statistical analysis (67 IBR in Group I and 72 IBR in Group II). Seventy-one patients (57.7%) had no delay (mean waiting time of 23 days). Fifty-two patients (42.3%) had delay longer than 31 days (mean waiting time of 66 days). Group I patients had a mean waiting time (standard deviation) of 38.8 (38) days and Group II patients 42.7 (24) days (p = 0.51). In this group of patients, SLNB before mastectomy and IBR does not significantly delay definitive breast cancer surgery.

Abstract T P287: Reasons for Delays in Door to Needle Time

Background: The National Quality Forum recently endorsed a performance measure for door-to-needle (DTN) time less than 60 minutes, with exclusion criteria for acceptable reasons for delay. However, the reasons for delay in timely treatment with tPA, and their impact on DTN times, are largely unknown. At our center we initiated the Hurry Acute Stroke Treatment and Evaluation-2 (HASTE-2) project to identify reasons for longer DTN. Methods: From 06/2012 to 06/2013 we encouraged treating physicians to fill out a 1-page case report form on opportunities for improvements and reasons for delays in treatment times, categorized according to systems-related delays (e.g. in patient registration, or in recognition of stroke symptoms and activation of the stroke) vs. medical/eligibility delays (e.g. management of concomitant emergent conditions or initial patient refusal). DTN data were analyzed from 113 consecutive patients presenting directly to the ER, treated with IV tPA within 4.5 hours of symptom onset. Results: Mean age was 71, 60/113 (53%) were women, median NIHSS was 13.5 and DTN was 57 minutes. Prospective data were recorded on the presence of absence of potential delays in 48/113 (42.5%); patients with missing data were somewhat younger (mean age 68.5 vs. 75.3, p=0.04) but did not differ in DTN or NIHSS. 52 different systems delays were identified in 30/48 patients (63%), and 15 different medical/eligibility delays were identified in 13/48 patients (27%). Medical/eligibility delays had the greatest impact on DTN: median 67 min [interquartile range 54-120] in patients with medical/eligibility delays, 47.5 min [40-66] in patients with only systems delays and 51 min [34-65] in patients with no delays (p=0.01). Conclusions: DTN may be prolonged for a variety of reasons. Up to 27% of patients have delays due to medical or eligibility-related causes that may be legitimate reasons for providing tPA later than the benchmark time of 60 minutes. Our difficulty in obtaining complete prospective physician documentation of reasons for delays suggests a need for improved chart documentation regarding DTN times.

A novel use of early radiation therapy in the treatment of hyperbilirubinemia in a patient with primary hepatic lymphoma and chronic hepatitis C.

Lymphomas arising in the liver are extremely rare. Here, we describe a case of Hepatitis C virus infection with primary hepatic lymphoma (PHL) presenting with hyperbilirubinemia. A 45-year-old African American male presented with abdominal pain, pruritus, and itching for two days. CT of abdomen and pelvis with contrast showed numerous masses in the liver. The liver biopsy was consistent with diffuse large B cell lymphoma (DLBCL). Conventional chemotherapy was avoided initially because of hyperbilirubinemia. Hence, radiation therapy was given initially to reduce his bilirubin levels and tumor size. The patient was able to complete six cycles of rituximab combined with cyclophosphamide, adriamycin, vincristine, and prednisone (R-CHOP) chemotherapy and achieved a complete response verified by positron emission tomography-computed tomography (PET-CT). PHL should be considered when there are numerous space occupying liver lesions seen on imaging. Hyperbilirubinemia may be a reason for delay in treatment for some of these patients. Hence, the role of radiation therapy prior to treatment with R-CHOP is an alternative to management for stage IV diffuse large B cell lymphoma.

Reasons for delay in treatment of breast cancer detected due to breast self-examination in women from the Lubelskie Region

A delay in diagnosis and treatment of breast cancer patients is observed despite access to modern diagnostic methods. The aim of the study was to evaluate time between the first symptoms of breast cancer and treatment commencement, as well as to analyze reasons for the delay The research was conducted on 260 breast cancer patients treated at the Oncology Center in Lublin between 2008 and 2011. 'Patient delay' was defined as the time gap of > 3 months between first symptoms of cancer and the doctor's appointment and 'system delay' as the time gap of > 1 month between the first medical consultation and commencement of treatment. Mean patient delay was 32.2 +/- 63.8 weeks. The main reasons were: disregard of symptoms (51%) and fear of being diagnosed with cancer (48%). Factors which significantly influenced the length of patient delay included: age > 65 years, non-regular gynecologic care, lack of prior cancer screening and lack of family history of breast cancer Mean system delay was 3.1 +/- 2.9 weeks. Tumors < 5 cm in diameter and clinical presentation other than a tumor significantly influenced the system delay A significant delay in diagnosis and treatment of breast cancer remains to be noted. Delay in seeking medical help was observed in 20% of the patients, whereas the referral was delayed due to system fault in 38% of the cases. Contrary to popular belief, patient delay (mean 32.2 +/- 63.8 weeks) is 10 times longer than system delay (3.1 +/- 2.9 weeks), suggesting an urgent need for further education of the general public and creating more accessible medical care.

Impact of Time from Diagnosis to Initiation of Curative-Intent Chemotherapy on Clinical Outcomes in Patients with Hodgkin Lymphoma

IntroductionHodgkin lymphoma is a highly curable lymphoid malignancy when treated with multi-agent chemotherapy regimens such as doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD). The optimal timing of curative intent chemotherapy and the impact of treatment delay on clinical outcomes in Hodgkin lymphoma are currently unknown. Patients and MethodsAdult patients diagnosed with Hodgkin lymphoma in British Columbia (BC) between January 1999 and December 2010 were identified in the BC Cancer Agency Centre for Lymphoid Cancer Database. Patients were included if they received at least one cycle of ABVD with curative intent. Patients treated with regimens other than ABVD and those treated with palliative intent were excluded. Additional demographic data were obtained from the BC Cancer Registry. Chemotherapy administration data, including drugs, dates administered, and treatment center, were obtained from the BC Cancer Agency provincial pharmacy database. Time to treatment initiation was defined as the time between the date of definitive histological confirmation of Hodgkin lymphoma and date of the first dose of ABVD. We then evaluated the effect of time to treatment initiation on overall survival (OS) and progression-free survival (PFS) at 5 years. ResultsA total of 879 patients were identified: 110 (13%) received ABVD within 2 weeks of diagnosis, 260 (30%) within 3 – 4 weeks, 405 (46%) within 5 – 8 weeks, and 104 (12%) beyond 8 weeks. Inpatient chemotherapy, elevated LDH, poor performance status, advanced stage, B symptoms, and bulky disease were all associated with treatment initiation within 2 weeks (p<0.01 for all factors). Age >45 and nodular lymphocyte predominant histology were significantly associated with treatment initiation >8 weeks (p<0.01 for all factors). Residence in a rural location at the time of diagnosis or the need to travel more than 200 km in order to receive initial chemotherapy were not associated with time to treatment (P = 0.26 and P = 0.90, respectively). Reasons for treatment initiation >8 weeks included systematic delays in the process of referral, staging, and scheduling of treatment (n=66), uncontrolled comorbidities (n=13), patient refusal of earlier treatment (n=9), pregnancy (n=5), revised pathological diagnosis (n=4), unknown cause of delay (n=4), and social or substance abuse factors (n=3).With a median follow-up of 5.6 years (range 1 month – 14 years) in living patients, the 5-year OS estimates were 90% (standard error (SE) 3%) for time to treatment<2 weeks, 93% (SE 2%) for 3-4 weeks, 92% (SE 1%) for 5-8 weeks, and 84% (SE 4%) for >8 weeks (P = 0.012). Five-year PFS estimates were 82% (SE 4%) for time to treatment<2 weeks, 79% (SE 3%) for 3-4 weeks, 86% (SE 2%) for 5-8 weeks, and 84% (SE 4%) for >8 weeks (P = 0.198). In multivariate analysis, age, gender, performance status, stage, and time to treatment were significantly associated with OS, while only age and stage were significantly associated with PFS. ConclusionsIn a publicly funded healthcare system with universal access to cancer treatment and standardized diagnostic review, initiation of ABVD beyond 8 weeks appears to be associated with worse OS but not PFS. Reasons for treatment delay in this group are heterogeneous and may be responsible for the detrimental effect on OS. Nonetheless, clinicians should make every effort possible to initiate curative-intent chemotherapy as soon as a diagnosis of Hodgkin lymphoma is established. Disclosures:No relevant conflicts of interest to declare.

The management of vulvar Paget's disease in 376 Caucasian and 283 Asian patients: Analysis of patient age and interval between symptoms and treatment.

e12057 Background: Vulvar Paget's disease is difficult to diagnose early because this is a rare disease with an incidence of 10 patients per one million females per year and often ocurrs in elderly women aged 60-70 years old. A randomized controlled trial, meta-analysis and evidence-based medicine are not suitable methods of improving the prognosis of this disease. Vulvar Paget's disease is an adenocarcinoma in situ and a malignant disease. Since early diagnosis and treatment is necessary to improve prognosis, we extracted the causes of late diagnosis and proposals to improve prognosis from the literature. Methods: Literature review was performed through Japana Centra Revuo Medicina and PubMed. Ten articles including our study on 283 Asian women and seven articles on 363 Caucasian women were collected and examined according to patient age, interval between the initial symptom and the start of therapy, reason for delay in treatment and measures to prevent delay. Results: The mean age was 69.2 years (min∼max: 41∼88) in Asian women and 67.8 years (35∼88) in Caucasian women. The interval between the initial symptom and treatment was 3.38 years (0.0∼17.0) in Asian women and 1.93 years (0.1∼16.0) in Caucasian women. Many authors indicated the delay between the initial symptoms to treatment was related with patient age, slight initial symptoms of the disease, slow progression and resemblance to eczema, mycosis and dermatitis. They also indicated that awareness of the disease among patients and doctors should be increased in order to promote early diagnosis. Conclusions: The mean patient age did not significantly differ among Asian and Caucasian women. The interval before treatment was longer for Asian women than for Caucasian women, because red exanthema was more easily distinguished on white skin than on pigmented skin. As a gynecologist, we must consider this disease a malignancy and provide rapid diagnosis in order to begin treatment without delay. Moreover, since there are some patients who rely on self-medication or folk medicine rather than consulting a doctor, education about the existence of vulvar Paget's disease must also be provided to the general public. No significant financial relationships to disclose.

Exploring the Reasons for Delay in Treatment of Oral Cancer

Oral cancer continues to be diagnosed and treated at a late stage, which has a negative effect on outcomes. This study identified and quantified delays in diagnosis and treatment. The authors conducted a study that included all new patients seen in the Department of Oral and Maxillofacial Surgery, University of California, San Francisco, between 2003 and 2007 who had a diagnosis of squamous cell carcinoma of the oral cavity. They identified the time intervals for six stages, beginning with the time at which patients first became aware of symptoms and ending with the time at which definitive treatment began. The total time from patients' first sign or symptoms to commencement of treatment was a mean of 205.9 days (range, 52-786 days). The longest delay was from the time symptoms first appeared to the initial visit to a health care professional (mean time, 104.7 days; range, 0-730 days). Health care professionals need to place greater emphasis on patient education to encourage early self-referrals. Patients should be encouraged to visit a health care professional when signs or symptoms of oral cancer first develop.

Can we improve the outcome of patients with advanced non-seminomatous germ cell tumors (NSGCT): 16 years experience of a single institution

5092 Background: We performed an analysis to review the outcome of patients (pts) with advanced NSGCT treated in Russian Cancer Research Center, since the introduction of modern chemotherapy (CT) at 1987. Moreover, we analyzed whether the results had improved over the last 6 years. Methods: 589 CT-naive pts with advanced NSGCT received induction etoposide- and cisplatin-based CT from 1987 to 2003. 534 (91%) pts had primary testicular tumor. Most commonly used CT regimens were EP (36%), BEP (52%), and C-BOP-3BEP (9%). Median follow-up was 60 months (range, 2–210) for the pts who survived. Pts survival was compared in accordance with two treatment periods, ‘before 1997’ and ‘after 1997’. Results: Survival rate differed significantly among the IGCCCG prognostic groups. There was a trend toward improved results over the last 6-year period (see table ). The poor prognostic group attained the most pronounced improvement in both PFS and OS (absolute benefit 14%). This fact could be explained by CT intensification (decrease in the number of reasons for treatment delay or dose-reduction on next cycle of CT) and by increase in the rate of post-CT resections of residual tumors. Conclusions: Despite the absence of major changes in advanced NSGCT treatment during the last two decades, there still exists opportunity to improve the outcome of the pts. [Table: see text] No significant financial relationships to disclose.

Educating and counseling of parents of children with attention-deficit hyperactivity disorder

Objective This study surveys the parents’ knowledge and attitude about attention-deficit hyperactivity disorder (ADHD), barriers to enrolment for treatment, parents’ source of information, reason for delay in treatment, and the first person who suggests the diagnosis of ADHD. Method The subjects of the study were the 119 parents and their children with ADHD. The parents and their children were interviewed and the mothers completed a self-reported questionnaire about ADHD. Results The knowledge about ADHD was relatively low. Half of them did not agree that ADHD is due to biological and genetic vulnerabilities and causation. Fifty-two percent of all the parents considered ADHD to be the result of parental spoiling. Only 6.2% reported that ADHD relate difficulties would persist for the whole life. About 40% of the respondents considered it as a sign of child independency. The main source of knowledge about ADHD was radio and TV. There were about 1.5 years between the time that the parents were suspected to the ADHD and the time they referred for the first time. The most common reason for the delay was lack of knowledge about where or whom they should refer to. Teachers were the first one who suggested the diagnosis of ADHD in most of the cases. Conclusion Knowledge about ADHD is low and barriers of referral are not usually overcome. Practice implications Educating and counseling of the parents should be directed toward emphasizing it as a biological problem, with concerns about its course. Also, targeting of the barriers in delaying the referral is an important issue. Medical personnel, especially GPs should be more informed about ADHD and play more active role in the treatment process.

Emergency Presentation of Abdominal Hernias: Outcome and Reasons for Delay in Treatment – A Prospective Study

Emergency hernia surgery is associated with a higher postoperative complication and a less favourable outcome. The aim of this study was to audit emergency presentations of abdominal hernias prospectively in order to identify delays in patient treatment. Prospective audit was carried out between January and September 2003 of all patients presenting acutely with symptomatic hernias. In total, 55 patients presented, 39 of whom needed surgical intervention. The emergency repairs were compared with a cohort of elective repairs performed in the trust at the same time. The median age was 77 years (range, 5-92 years; 35 male, 20 female). The distribution of the hernias, requiring surgery, was inguinal (19), para-umbilical (10), incisional (5) and femoral (5). The overall complication rate was 46.2% and the in-patient stay was 4 days (range, 1-49 days). Six patients required small bowel resection. Conservative management was identified as a key contributing factor in the delay of treatment. There was a significant increase in the in-patient stay, the early complication rate and the small bowel resection rate in the emergency repairs. Patients with a symptomatic hernia should be offered elective, surgical repair. Non-operative management is inappropriate for the vast majority of cases, especially when many repairs may be performed with local anaesthetic infiltration. Clinicians should be aware of the high morbidity associated with the emergency repair of abdominal hernias in the elderly.

Contextual Fundamentals, Models, and Active Management

<b>Objective:</b> To identify reasons for delay in management of patients with cauda equina syndrome (CES) and to determine commonly presented features of CES. <b>Methods:</b> Retrospectively, the presenting features and management of patients treated for CES over a 4-year period were reviewed. <b>Results:</b> Reasons for delay in treatment were identified in over half of the patients. <b>Discussion:</b> Most patients do not present with all the characteristic features of CES. Sacral sensory loss is a sensitive and relatively specific sign for diagnosing CES.

Risk factors for treatment delay in pulmonary tuberculosis in Recife, Brazil.

BackgroundTuberculosis is still a great challenge to public health in Brazil and worldwide. Early detection followed by effective therapy is extremely important in controlling the disease. Recent studies have investigated reasons for delays in treatment, but there is no agreed definition of what constitutes an "acceptable" delay. This study investigates factors associated with total delay in treatment of tuberculosis.MethodsA cohort of adult cases of pulmonary tuberculosis diagnosed over a two-year period was studied. Patients were interviewed on entry, reporting the duration of symptoms before the start of treatment, and sputum and blood samples were collected. It was decided that sixty days was an acceptable total delay. Associations were investigated using univariable and multivariable analysis and the population attributable fraction was estimated.ResultsOf 1105 patients, 62% had a delay of longer than 60 days. Age, sex, alcoholism and difficulty of access were not associated with delays, but associations were found in the case of unemployment, having given up smoking, having lost weight and being treated in two of the six health districts. The proportion attributable to: not being an ex-smoker was 31%; unemployment, 18%; weight loss, 12%, and going to the two worst health districts, 25%.ConclusionIn this urban area, delays seem to be related to unemployment and general attitudes towards health. Although they reflect the way health services are organized, delays are not associated with access to care.

The Pharmacist’s Role in Reducing Patient Delay in Seeking Treatment for Acute Myocardial Infarction

The most common reason for delay in treatment of an AMI is the patient's failure to seek care promptly. Individuals diagnosed with CHD, including those who have experienced an AMI, are considered to be at high risk for an AMI. These patients have the same or greater delay times as individuals without prior AMI or CHD. Pharmacists interact with these high-risk individuals and their families frequently in person or by telephone. During these interventions, they have the opportunity, through education and counseling, to improve their patients' understanding of early symptoms of AMI and the need for and benefits of prompt evaluation and treatment. Hearing this message from their pharmacist and from other health care providers in other settings will hopefully lead the high-risk individual to seek care promptly when needed. Successfully conveying this message could effectively reduce the morbidity and mortality associated with CHD.