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Rozniatowski Olivier

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Psychosocial factors  involved  in delayed  consultation  in  head and  neck



cancer patients






Rozniatowski Olivier



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


Depression Scale).

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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


seeking consultation.















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.

Rozniatowski Olivier

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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

Rozniatowski Olivier

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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).












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