Table 3UROLOGICAL CANCER: delay and diagnostic difficulties

AuthorSettingDescriptionNo.InclusionExclusionResultsQuality
Khadra et al, 2002UK, Primary CareThe aims of this study were to investigate the level of awareness of testicular cancer (TC) and practice of testicular self examination (TSE) in male GP attenders, and to see if TSE was related to age, marital status, education, ethnicity, social class, knowing someone with TC, having attended a Men's Health Clinic and having heard of a TC awareness campaign.
The authors recruited men from two English general practices, one inner city and one suburban. Confidential questionnaires were given out to consecutive male patients between the ages of 18 and 50 years attending the GP surgeries over a period of 1 month. The data were analysed using SPSS.
202Male patients between the ages of 18 and 50 yearsNot explicitly mentionedAlthough 91% of men claimed to be aware of TC, only 26% knew both the age group most affected (25–34 years) and that TC can be curable if detected early.
Forty-nine per cent of responders had carried out TSE in the past year, but only 22% did so according to recommendations, i.e. feeling for lumps on a monthly basis. TSE was associated with age >35 years, white ethnicity, having correct knowledge of TC, knowing someone with TC, having attended a Men's Health Clinic and having heard of a TC awareness campaign.
TSE was suggested by the media to 56% of those who examined themselves and by a nurse or GP to only 16%. Forty-eight per cent of those carrying out TSE had received written instructions, and 10% had received a testicular examination by their GP. Only 3% had attended a Men's Health Clinic in the past. Of those 103 responders not carrying out TSE, 71% said they did not know what to do, 27% said they were too busy and 2% were afraid they might discover a lump. Eighty-five per cent (169/199) of the men were keen to find out more about TSE and 67% (136/202) would attend a Men's Health Clinic if one were set up in their GP's surgery.
Lechner et al, 2002Netherlands Population basedThis study analysed what determinants are important to describe and explain the intention of testicular self-examination (TSE).
The authors recruited the subjects by approaching several high schools and asking them if they were prepared to let the researcher administer the written questionnaire among their male high school students aged 15– 20. Four schools were needed to get the needed sample for the study, and they were randomly selected from the available six schools.
The questionnaire assessed determinants, including knowledge, attitude (positive and negative consequences, anticipated regret, and moral obligation), social influence (social norm, social support and modelling) and self-efficacy. Data analysis included basic descriptive statistics of the respondents. Statistical differences between the various intention groups were analysed using one-way ANOVA with Scheffé's multicomparison tests. Linear regression analysis was used to assess the predictive value of the determinants for the intention to perform TSE. All analyses were performed using the SPSS-X statistical program (SPSS Inc., 1988) (differences were significant at P < 0.05).
274Young men aged 15–19 attending senior high school.Not explicitly mentioned.Knowledge of testicular cancer and TSE was very low: 74% had never heard of testicular cancer and only 3% of all students had ever heard of TSE. Of all subjects, only 2% (n = 5) reported that they regularly performed TSE. Since knowledge and behaviour levels were so low, they showed no significant correlation with intention or any of the other determinants related to TSE. After hearing of TSE (through the questionnaire), 41% of students had a positive intention to perform TSE (32% positive, 9% very positive), while 27% had a negative intention to do TSE (20% negative, 7% very negative). The rest of the subjects had not yet formed an intention.
The highest correlations with intention were found for the moral obligation that subjects experienced to perform TSE, their self-efficacy expectations, the expected positive consequences of TSE, the social norm that subjects experienced and the regret they expected to feel if they did not perform TSE.
The various intention groups (positive, neutral and negative) differed significantly on almost all of the determinants. Multiple regression analysis showed that young men who where anxious about TSE and those who were not anxious had different determinants explaining the variance in the intention to perform TSE regularly (R2 = 41–57%).
Reliability analysis showed that the assessment of some concepts still has room for improvement. Furthermore, there is still limited insight in the validity of the concepts assessed. Therefore, further research is needed in order to get more insight in the validity of the concepts assessed and to find out whether the assessments of the different concepts of the model can still be improved.

Since hardly any of the young men in this study performed TSE regularly, the determinants of behaviour were not assessed. Instead, the determinants of intention were analysed.
Mansson et al, 1993Sweden, Population based study (Primary and Secondary Care)The study was undertaken to investigate various factors which may play a role in patient’s delay and doctor’s delay in the diagnosis of bladder cancer.
The authors examined the clinical records of all patients with a diagnosis of bladder cancer as gathered from a regional tumour registry. Variables extracted from the records included onset date and specific pattern of symptoms, date and place of first medical consultation, referral patterns, investigations, and date of diagnosis, amongst others.
The extracted variables specially studied in each case were patient’s delay and doctor’s delay. A questionnaire was sent to patients who were still alive on January 1, 1991. The replies were designed to reflect how seriously the patients viewed their first symptoms of bladder cancer, their experiences of previous serious or protracted illness, and their habitual perception of bodily changes and level of general education.
Intergroup differences in patient’s and doctor’s delay were analysed with Wilcoxon’s rank sum test and Kruskal-Wallis test. The χ2 test was used to compare categorical variables. All tests were two-sided.
343Patients with diagnosis of bladder cancer established in 1988.Patients with non-malignant disease (n=16), recurrent bladder cancer (8), prostatic cancer (1), pathologist’s report dated 1989 (20), or missing records (5).The clinical records of 343 patients were examined, and 203 patients completed the questionnaire (88.6% of those eligible).
Macroscopic haematuria was the commonest symptom bringing the patient to the doctor. Urgency was more common in advanced than in superficial cancer (51% vs.34%, p<0.002). No correlation was found between presence of haematuria and tumour category. 161 (67%) patients initially consulted a primary unit of the health services (mostly a general practitioner) and 51 (15%) a private practice (mostly a general practitioner or gynaecologist). The remaining 118 patients presented at a hospital. Three patients (1%) never sought medical advice and were diagnosed at post-mortem examination). The median patient’s delay was 15 days (mean 141, range 0–2,857). There was no relationship between this delay and age or gender.
The type of symptom was an important factor in patient’s delay. Neither urgency of micturition nor pain prompted the patient to seek medical advice as quickly as haematuria (median 45 and 38 vs. 5 days, p<0.001). Although the difference was not statistically significant, median patient’s delay was longer in patients with advanced cancer than in those with superficial tumour. Amongst the responders to the questionnaire, no correlation was demonstrable between patient’s delay and level of education, perceived seriousness of initial symptoms, or civil status. The median doctor’s delay was 62 days overall. It was longer for women than for men (76 vs. 59 days, p<0.05). The initially consulted health-service level was a major factor in doctor’s delay (p<0.001), with median range from 78 days for patients initially seen in a primary care unit to 21 days when the patient came directly to a department of urology, but the longer median delay was not due to delayed referral to a specialist, since in the total series doctor’s delay phase A was only 6 days, whereas phase B was 47 days (suggesting considerable waiting time in the referral system). The use of urine cytology and intravenous urography in general or private practice was associated with some, but not significant, shortening of doctor’s delay. As in patient’s delay, the nature of presenting symptoms greatly influenced doctor’s delay, which was shorter with haematuria plus pain than with haematuria only, and longest when urgency was the only symptom (median 44, 53 and 114 days, p<0.001). Patient’s age influenced doctor’s delay. The median thus was less in patients younger than 70 years than in older patients, viz. 54 and 69 days (p<0.01).
The power to detect true median differences is low, since the delay variables are very skewly distributed and have large variances.

Good retrospective observational study. Some bias may have been introduced as respondents to questionnaire differ from non- respondents, i.e. alive patients, younger, and with earlier tumour stage.
Mommsen et al, 1983Denmark, Primary and Secondary CareThe purpose of this study was to elucidate causes of delay.

The authors interviewed all consecutive patients with newly diagnosed bladder tumour admitted to a department of Oncology and Radiotherapy during a 3-year period beginning in September 1977.

The interview concerned symptom, some demographic variables and the time intervals under study (phases A, B, and C).

The statistical procedures included χ2 test.
212 patientsPatients with newly diagnosed bladder tumour.Terminal, intractable cases.The presenting symptom was haematuria, which commonly was painless, in 79% of the patients. The interval from onset of symptoms until treatment averaged 28 weeks (median = 15 weeks). The general practitioner delay comprised half of the total delay. Half of the patients consulted their general practitioner within a week after onset of the presenting symptom. A higher percentage of men than of women had a delay of 13 weeks. Fewer women than men (62% and 82%) were referred to hospital within 12 weeks of the index consultation with the general practitioner (χ2 = 8.97; d.f.=1; p <0.005). Of the patients with haematuria, ≥ 13% of the men but 35% of the women were referred to hospital after 13 weeks or more (χ2 =9.70; d.f.=1; p<0.005). Cystitis as the presenting symptom was associated with later referral to hospital than haematuria; this was most pronounced for men (χ2=12.56; d.f.=1; p<0.005).The authors confirmed the reliability of the time data by comparing the intervals reported by the patients with corresponding information derived from the general practitioner’s records in 10% of a random sample of these patients.
Skewness in distribution of delay. Small study with limited power.
Wallace et al, 1999UK, Secondary CareThe authors examined the relationship between delay in presentation of patients with bladder cancer and tumour stage and material deprivation. Data on delay periods to treatment, tumour characteristics, occupation and postcodes were collected for patients with urothelial cancer presenting to a Regional Cancer Intelligence Unit. The Townsend material deprivation score was derived from the patient’s postcode (the score assesses four variables measuring unemployment, overcrowding, wealth and income).1537Patients with urothelial cancer.Not explicitly mentioned.A delay of < 2 weeks in the referral to hospital was associated with a 6% improvement in survival (P = 0.018); shorter delays to hospital appointment correlated inversely with survival (P < 0.001). The overall delay time and delay to hospital admission did not correlate with survival. The deprivation scores showed no correlation with delay times, smoking or T-category of tumour. Material deprivation was correlated with low tumour grade (P = 0.004) and better survival (P = 0.02).Poor definition of delay and description of methods (only abstract was available for inspection). Most of the study relates to the association between delay and survival, which as such is not relevant to the guidelines.
Wallace et al, 2002UK, Secondary care.The authors attempted to collect data prospectively on all newly diagnosed cases of urothelial cancer in the West Midlands from 1 January 1991 to 30 June 1992. The data collected included the dates of onset of symptoms, first referral by the GP, first hospital appointment and first definitive treatment. Clinical details collected included the presence or absence of haematuria (macroscopic or microscopic), the number, size and type of tumours, and the findings of the bimanual examination. Details of patient characteristics were also collected. In addition, patients were asked to complete a questionnaire on their smoking and occupational history.

Associations between the patient characteristics and median delay times were analysed using Pearson's chi-squared test for categorical data and the Mann–Whitney U-test for continuous data.
1537 patientsNot explicitly mentionedNot explicitly mentionedThe median (IQR) Delay 1 was 14 (0– 61) days. Patients with a longer delay were more likely to present with a higher stage tumour (P=0.04). Patients with an unknown haematuria status were more likely to have a shorter delay (P<0.001). No other patient or tumour characteristics showed a significant difference above or below the median delay. Delay 1 had a significant effect on survival; patients with a delay of <14 days to referral had an improved survival of 5% at 5-years compared with those who had a delay of >14 days (P=0.02). Adjusting for tumour stage, there was a trend for patients with a shorter Delay 1 to have a better survival (P=0.06).
The median Delay 2 was 28 (7–61) days. Patients known to have had macroscopic haematuria (n=1032) were more likely to have a shorter delay than those known to have had microscopic haematuria (n=70); patients with an unknown haematuria status were more likely to have a longer delay (P<0.001).
There were no other significant differences in patient or tumour characteristics above or below the median delay. Patients who had a shorter Delay 2 had a significantly worse survival (P=0.001). Survival by Delay 2 after adjusting for tumour stage similarly showed that patients with a shorter Delay 2 had significantly worse survival (P=0.001). The median total delay was 110 (62– 209) days. Longer delays were significantly associated with women (P=0.05), younger patients (P=0.03), non-smokers (P=0.04) and patients with a low risk of occupational exposure (P=0.04). No other patient or tumour characteristics showed significant differences above or below the median delay. The total delay had no effect on survival (P=0.17); this was also true after adjusting for tumour stage (P=0.43).
For prognostic factors, there was no survival difference for sex (P=0.92), haematuria (P=0.39) and number of tumours (P=0.13), both in the log-rank analysis and Cox regression models.
Clinically based data (presence or absence and degree of haematuria) and more detailed epidemiological data (smoking status, risk of occupational exposure) relied upon clinicians and patients to complete questionnaires and some data are incomplete.

From: Appendix B, Evidence Tables

Cover of Referral Guidelines for Suspected Cancer in Adults and Children
Referral Guidelines for Suspected Cancer in Adults and Children [Internet].
NICE Clinical Guidelines, No. 27.
Clinical Governance Research and Development Unit (CGRDU), Department of Health Sciences, University of Leicester.
Copyright © 2005, National Collaborating Centre for Primary Care.

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