There is concern that delays in diagnosis may be a contributing factor in the high frequency of advanced disease at presentation (2). Common symptoms at the time of presentation of lung cancer include cough, dyspnea, chest pain, fatigue, chest infection, hemoptysis and weight loss (3-5). Significant overlap occurs between these symptoms and symptoms of other chronic respiratory conditions such as chronic obstructive pulmonary disease (COPD). Such overlap in symptoms might lead to delay in recognition of a lung cancer diagnosis.

Several authors have investigated the time taken to initiate diagnosis and treatment of patients with lung cancer (3,6-10). Koyi et al (10) prospectively evaluated the time from onset of first symptoms until commencing treatment. They reported that the median time from patients’ first report of symptoms until the start of treatment was around six months (189 days). They observed delays in presentation to a family doctor (median 21 days), referral to a specialist (median 56 days) and time taken for subsequent investigations (median 33 days). Additionally the type of symptoms at presentation appears to influence the time to delay. Bjerager et al reported that patients with typical lung cancer symptoms such as cough, dyspnea and hemoptysis waited a median 29 days for referral for investigation (3). However, patients with atypical symptoms such as bone and joint pain, or fatigue waited a median of 104 days for referral. A retrospective audit of cancer cases in Scottish family practices demonstrated that lung cancer patients waited longer for specialist referral than patients with most other cancers (7). Missed opportunities to establish a lung cancer diagnosis might be a contributing factor to this. A review of 587 new lung cancer cases at two tertiary institutions reported that 38% of cases had missed opportunities to establish a diagnosis of lung cancer (6). This group of patients had a substantially longer time to diagnosis than patients without missed opportunities (132 vs 19 days).

Data were collected over a three month period. Consecutive patients meeting the eligibility criteria were approached by a research assistant at their initial or second visit. Information was provided about the purpose of the study and patients were invited to participate. Arrangements were made with consenting patients, to conduct a telephone interview with the research assistant in the near future. Informed consent was obtained from all study participants and the study was approved by the Hamilton Health Sciences Research Ethics Board.

Structured telephone interviews were conducted with consenting patients using a standardized data collection form. Information was collected on patient demographics, stage and type of cancer, date and type of presenting symptoms, initial presentation and management by a family doctor, date of specialist referral, diagnostic tests ordered by both the family doctor and specialists, plus date of referral to cancer centre. The dates of physician appointments and diagnostic tests were verified by way of the family doctor or patient chart. Participants were also asked to describe their own delay in presentation to a family doctor, as well as perceptions of a delay by their family doctor, respirologist, thoracic surgeon, medical oncologist and radiation oncologist. Reasons for delays were recorded and categorized after data collection.

The sample size was based on the number of patients seen during the time period rather than a priori calculations. The data analysis was primarily descriptive. Categorical variables were summarized using proportions and continuous variable with median and standard deviation or interquartile range (IQR). The primary outcome of the study was the time taken from initial onset of patients’ symptoms to commencement of treatment.

•T1: time from initial symptoms to first presentation to a family doctor or emergency department

•T2: time from initial presentation to the last date of diagnostic testing ordered by the family physician

•T3: time from initial presentation to the first appointment with a specialist, either directly to the JCC or to a respirologist or thoracic surgeon

•T4: time between the initial appointment with the specialist and the last date of additional diagnostic testing

•T5. Time from JCC referral to initial consultation

•T6: time from initial contact with a medical or radiation oncologist to the starting date of treatment, defined as chemotherapy, radiation therapy, or the decision not to pursue treatment

Patients spent a significant time waiting in each time period (Table 3). Patients waited a median of 21 days (IQR 5-51d) from the onset of initial symptoms until first presentation to a doctor. An additional 22 days (IQR 0-38d) were taken to complete initial investigations by the family physician and a median of 27 days (IQR 12-49d) from presentation to family doctor until specialist referral. The median time from specialist referral to referral to JCC was 23.5 days (IQR 10-58d) and an additional 12 days (IQR 6-18d) occurred from referral to initial consultation. The median time from consultation to commencement of treatment was 10 days (IQR 2-28d). In total, patients spent a median of 138 days (IQR 19-174d) waiting from the initial onset of symptoms to commencement of treatment.

Patients’ perception of delays varied according to the time period. Twenty four patients (46%) perceived that delays occurred from the onset of symptoms to presentation to the family doctor. The most common reason was the patients’ perception that the symptoms were not serious (n=11). On the other hand only 12 patients (23%) believed there was a delay in initial investigations by their family doctor. A larger proportion of patients (n=19, 37%) perceived delays in waiting for tests arranged by a specialist. These delays were primarily perceived to be waiting for tests. Interestingly, the actual wait times in each of these time periods were similar. Patients were asked to rate their satisfaction on a scale of 1-5 (Fig 2). Thirty one patients (61%) were satisfied with the amount of time spent waiting for tests, as well as their overall satisfaction.

It is apparent that some patients are seen by multiple specialists before having a treatment decision finalised (Table 4). All patients saw at least two specialists including a medical or radiation oncologist. However, 24 (46%) saw four specialists including at least one medical or radiation oncologist. All patients had multiple investigations performed. These were ordered by multiple physicians (Table 5). The investigations ordered most frequently by specialists include bronchoscopy (90%), CT scan (65%) and bone scan (65%).

However, recommendations about wait times are largely empirically based. It is unclear what, if any impact delays in diagnosing and treating lung cancer might have on treatment outcomes. There are some data examining outcomes of patients with stage I and II NSCLC waiting for surgery (15). Patients waiting longer for surgery did not have any detriment in their survival. It is possible though, that patients with more advanced disease might progress during these wait times and no longer be eligible for aggressive treatment options. Additionally, delays in diagnosis can result in psychosocial morbidity (16,17).

Our data would suggest that delays in the diagnosis occur at each step in the process. However, it is apparent that two major themes occur. The first issue is that there appears to be a lack of recognition of the presenting symptoms from lung cancer. Many patients delay presenting to their doctor because they initially think the symptoms are not serious. Once they do present to a doctor they often receive treatments such as antibiotics, inhalers or cough syrup that would be more appropriate treatments for infection. This issue is highlighted by the observation that patients presenting with respiratory symptoms had a significantly longer time from initial presentation to commencement of treatment than those with atypical symptoms. The presence of such typical symptoms may result in more uncertainty about the initial diagnosis and longer time to diagnosis. However, these findings though are opposite to those observed by Bjerager, who found that patients with atypical symptoms had a much longer time to diagnosis (3).

The other significant issue contributing to the delay in starting treatment is the time taken to complete diagnostic investigations. Our patient sample saw up to four specialists before commencing treatment, and had investigations ordered by multiple physicians. This complex diagnostic process adds considerable time to the entire process.

There is a strong need to simplify the diagnostic process for patients with lung cancer. Our data would suggest that physicians and people in the community require education about the common presentations of lung cancer patients. This might raise awareness of lung cancer and help in part to overcome the initial belief that patients’ symptoms are not serious. Nihilism still exists about treatment options for lung cancer. There is little research though, on knowledge transfer strategies to increase community physician knowledge and awareness of treatment options. However, the largest benefit in shortening the time taken to diagnose and commence treatment would appear to be in simplifying the diagnostic process. Delays in completing diagnostic tests are only compounded by the fact that tests are often ordered sequentially by multiple physicians. One solution would be the establishment of diagnostic assessment units (DAUs). DAUs offer a number of advantages including ease of access, access to multidisciplinary teams, and offer the potential of collaborative research, provider training opportunities and may enhance quality improvement and performance measurement. A systematic review of DAUs has shown that they reduce the time required to access diagnostic services, reduce patient short term anxiety and increase patient satisfaction, although most data exists in breast cancer diagnostic assessment units (18). There is a paucity of data though, on longer term disease outcomes.