Psychosocial factors involved in delayed consultation in head and neck
Psycho-oncology Unit, Centre Oscar Lambret, 59020, Lille, France
keywords : Head and neck cancer, oral cavity, delay in consultation, anxiety, depression,
social isolation, spouse, partner
Abstract : Background. In the north of France, a delay in primary consultation has been noted among head
and neck cancer patients. This group is often correlated with lower socio-economic status and a lack of medical
information. Therefore, the choice to seek consultation is often influenced by symptoms such as pain and change
in the size of tumors in the neck.
Aims. We studied this delay in seeking consultation, focusing on psychosocial variables such as professional and
social background, the involvement of a spouse/partner, and the presence of anxiety and depression.
Methods. Two rating scales were administered to 50 patients with large tumors (T3/T4) compared with 50
patients with small tumors (T1/T2): (i) a 17 item questionnaire assessing socio-demographic data, presenting
symptoms, factors generating the consultation, and reasons for delay ; (ii) the HADS : (The Hospital Anxiety and
Results. Both groups were predominantly male and working-class. Significant differences were observed in time
since symptom onset, and conscious delay in seeking medical attention. The sample involving large tumors was
characterized by lower involvement of a spouse/partner, conscious delay prior to first consultation, greater social
isolation, fewer medical visits, and lower HADS anxiety scores. The sample with small tumors sought
consultation sooner and was characterized by greater involvement of a spouse/partner, correlated with significant
anxiety. Depression was not a factor influencing delay within either group.
Conclusions. The interpersonal relationship with a spouse/partner seemed to be essential in the dynamics
surrounding consultation. Anxiety, rather than socioeconomic status, was a discriminating factor in the delay in
Faced with the onset of head and neck cancer symptoms, patients do not always behave in an
appropriately responsive manner. Many patients don’t react objectively to their symptoms by
seeking a medical consultation.
In the north of France, a delay in the time to first consultation has been observed among head and neck cancer patients1a. The consultation is often prompted by intolerable pain or by
tumor’s size causing a major functional disturbance.
In this region of France, epidemiological data1b show a tremendously high incidence of
cancer, especially for this type of cancer.
For head and neck cancer, the annual incidence per 100,000 inhabitants is 16 for the USA; 18
for the EEC; 37 for France and 39 for the north of France region alone1b , this latter
demonstrating the highest incidence in the world.
Relatively little is known about the reasons why, in the north of France, there is such a delay
in seeking medical care for these tumors.
Several studies have examined factors that might explain the delay, though none have studied
these findings specifically with regard to our region. These factors include:
Socioeconomic conditions2 : patients belonging to higher social classes may show less delay in seeking consultation3.
The presence of a partner may also play a role in seeking early consultation4,5
As a defense mechanism, denial may help with coping in the early stages by negation of the disease and its symptoms6.
Lastly, the existence of an underlying psychopathology, such as a depressive disorder, anxiety disorder or addiction may contribute to the delay7. For instance, the excessive consumption of
alcohol and tobacco in this kind of population has classically been understood as a self-
destructive behavior, one which may correlate with delay in seeking help.
Many other studies8,9 have shown a correlation with poor socioeconomic conditions, but only
in underdeveloped countries.
Thus, the aim of this study was two-fold :1) to quantify the psycho-social characteristics of
these patients and 2) to better define the reasons that lead this type of patient to seek
consultation belatedly, in the face of sizeable lesions developing over the course of weeks or
Patients and methods
Our sample was composed of 100 head and neck cancer patients, specifically those with
oropharyngeal and oral cavity tumors. Nasopharyngeal cancers were excluded due to their
low incidence and their specific epidemiology (involvement of viral infections, genetic
Laryngeal and hypopharyngeal cancers were also excluded since they induce impairment in
phonation (spontaneously, or due to tracheotomy or tracheostomy) which would not permit an
interview under the same conditions as that of other patients. Moreover, this type of deep
lesion could generate a selection bias, since the first clinical signs are not easily discovered by
patients themselves or by a general practitioner. Furthermore, due to their communication
impairment, all patients with laryngectomy or tracheotomy were also excluded from the
Data collection was performed by a psychologist using a semi-structured interview. Patients
were asked to speak in a narrative fashion about the onset of their illness.
At the Oscar Lambret Center, between September 2000 and July 2002, one hundred patients
with head and neck cancers were included and divided into two groups :
Fifty patients with large lesions: patients who started treatment at an advanced stage of the disease (Stage T3/T4 from the UICC classification11).
Fifty patients with smaller lesions, who constituted the control group: patients who started
treatment at an earlier stage of the disease (stage T1/T2 from the UICC classification).
1a. Le Cancer des Voies Aéro-Digestives Supérieures dans le Nord Pas-de-Calais. Analyse
descriptive de la prise en charge. Rapport technique réalisé par l’URMEL et l’URCAM. PRS
“Challenge” 2001; 3:39.
1b. Le Cancer des Voies Aéro-Digestives Supérieures dans le Nord Pas-de-Calais. Analyse
descriptive de la prise en charge Rapport technique réalisé par l’URMEL et l’URCAM. PRS
“Challenge” ; 2001; 3:3-4.
2. Oji C. Late presentation of orofacial tumours. J Craniomaxillofac Surg 1999; 27: 94-99.
3. Hackett TP, Cassem NH, Raker JW. Patient delay in Cancer. N Engl J Med 1973; 289 :14-20.
4. Kreitler S, Chaitchik S, Rapoport Y, Algor R. Psychosocial effects of level of information and
severity of disease on head and neck cancer patients. J Cancer Educ 1995; 10:144-154.
5. Humpris GM, Ireland RS, Field EA. Randomised trial of the psychological effect of information
about oral cancer in primary care settings. Oral Oncol 2001; 37: 548-552.
6. Worden JW, Weisman AD. « Do cancer patients really want counseling ? », Gen Hosp Psychiatry
1980; 2 :100-103.
7. Kugaya A, Akechi T, Okuyama T, Nakano T, Mikami I, Okamura H, Uchitomi Y. Prevalence,
predictive factors and screening for psychologic distress in patients with newly diagnosed head
and neck cancer. Cancer 2000 ; 88 : 2817-2823.
8. Kerdpon D, Sriplung H. Factors related to delay in diagnosis of oral squamous cell carcinoma in
southern Thailand.Oral Oncol. 2001;37(2):127-31.
9. Oburra HO. Late presentation of laryngeal and nasopharyngeal cancer in Kenyatta National
Hospital. East Afr Med J. 1998;75(4):223-226.
10. Le cancer dans le Nord Pas de Calais, incidence 1998. Données issues de l’assurance maladie,
analyse complémentaire. 2001;2: 17.
11. American Joint Committee on Cancer. Manual for staging of cancer. Philadelphia : JB Lippincott,
12. Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983;
13. Razavi D, Delvaux N, Farvacques C, Robaye E. Validation de la version française du HADS dans
une population de patients cancéreux hospitalisés. Rev Psychol Appl 1989; 39(4):295-308.
14. Samet JM, Hunt WC, Lerchen ML, Goodwin JS. Delay in seeking care for cancer symptoms: a
population-based study of elderly New Mexicans. J Natl Cancer Inst. 1988;80(6):432-438.
15. Rubright WC, Hoffman HT, Lynch CF, Kohout FJ, Robinson RA, Graham S, Funk G, McCulloch
T. Risk factors for advanced-stage oral cavity cancer. Arch Otolaryngol Head Neck Surg 1996
Jun ;122(6) : 621-626.
16. Kowalski LP, Carvalho AL. Influence of time delay and clinical upstaging in the prognosis of
head and neck cancer. Oral Oncol 2001;37(1):94-98.
17. Kumar S, Heller RF, Pandey U, Tewari V, Bala N, Oanh KT. Delay in presentation of oral cancer:
a multifactor analytical study.Natl Med J India. 2001;14(1):13-17.