Delay in referral of oropharyngeal squamous cell carcinoma to secondary care correlates with a more advanced stage at presentation, and is associated with poorer survival

Abstract

Squamous carcinoma of the oropharynx presents with symptoms common to many benign diseases, and this can cause delay in referral to secondary care. We investigate delay in referral, defining this as the time from symptom-onset to date of general practitioners referral letter to secondary care, and the effect of that delay, using a retrospective case notes based study of patients presenting at our institution with oropharyngeal squamous carcinoma between 1995 and 2005. Using correlation analysis and ordinal regression, we examined the relationship between increased referral delay from primary care, clinical stage at presentation, and survival. Increasing time from symptom onset to referral to secondary care was positively correlated with more advanced disease stage at presentation (r(s) = +0.346, P = 0.004). This was confirmed with ordinal regression modelling (delay estimate = 0.045, P = 0.042). Patients with delay of less than 6 weeks had significantly improved survival compared to those with a delay of greater than 6 weeks (P = 0.032). For every 1 week of delay in referral, we estimate that the stage of presentation will progress by 0.045 of 'a stage'.

Figure 1

Consort diagram for case selection.

Figure 2

Mean delay (in weeks) by clinical stage at presentation (error bars represent 95% confidence interval of mean).

Figure 3

Kaplan–Meier survival analysis of patients with a greater than 6 weeks delay in referral compared to patients with less than 6 weeks delay.