Oral Oncology (2005) 41, 142146

http://intl.elsevierhealth.com/journals/oron/

Scheduling delay in oral cancer diagnosis:

a new protagonist
P. Diz Dios*, N. Padron Gonzalez, J. Seoane Leston, I. Tomas Carmona,
J. Limeres Posse, P. Varela-Centelles

Department of Special Needs, School of Medicine and Dentistry, Santiago de Compostela University,
36203, Spain

Received 16 July 2004; accepted 23 July 2004

KEYWORDS Summary Diagnostic delays in oral cancer have been classified as patient delay
and delay by the clinicians. However, the influence of the accessibility (schedul-
Oral cancer; ing delay) to the health care system in oral cancer diagnosis has not been studied
Early detection; before.
Diagnostic delay; To assess scheduling delay, a descriptive, cross-sectional study was designed. This
Dental hygienists study was based upon role-play telephone conversations with two standardised
patients (lingual ulceration-SP1 and patient seeking fixed prosthodontics-SP2). that
followed a structured script. The variables considered in the study were days to go
until the arranged appointment, professional degree of the contacted person and
referral to other provider of care.
The scheduling delay for SP1 reached a median value of 1 day, and for SP2 was
6 days. When the professional degree (receptionist vs GDP) of the person arranging
the appointment for the patient with lingual ulceration was considered, the sched-
uling delay was significantly shorter when the appointment was fixed by the GDP
(Xei
X
e j 4:5; 95%CI
7.48,
1.51). GDPs gave priority to the patients with lin-
gual ulcerations over those demanding fixed bridgework ( X ei
X
e j 6:48;
95%CI
9.46,
3.50).
The GDPs showed a high level of awareness of the oral cancer, however, educa-
tional interventions seem to be necessary for dental surgery receptionists.
c 2004 Published by Elsevier Ltd.

Introduction

The incidence of cancer in Europe shows consid-

erable geographic diversity: France reports the
*
Corresponding author. Address: C/Panama 2; 2dcha 36203
highest level (12.4 per 100.000 inhabitants per
Vigo, Pontevedra, Spain. Fax: +34 981 562226. annum in Bas-Rhin), whereas the Nordic countries
E-mail address: pdiz@usc.es (P.D. Dios). show relatively low figures (1.11.7 per 100.000


1368-8375/$ - see front matter c 2004 Published by Elsevier Ltd.
doi:10.1016/j.oraloncology.2004.07.008
Scheduling delay in oral cancer diagnosis: a new protagonist 143

per annum).1,2 In Spain oral cancer incidence ranges upon role-play telephone conversations with two
between 1.0 and 5.2 within the population (ad- standardised patients that followed a structured
justed to the world population, per 100.000).2,3 script that included as initial statement summariz-
Moreover, epidemiological studies have shown an ing the reason for attendance, age, sex, pathochro-
annual increase in oral cancer mortality from 1975 nia and clinical aspect of the lesion.
to 1994, of 25% for males and 9% among females.4 The standardised patient no. 1 (SP1) was a
These facts make oral cancer a major public health 63 year-old male, smoker (40 cig./day) who de-
problem in Spain. scribes an ulcerated lesion on the tongue with fea-
Variables like age, sex, nutritional or immunolog- tures of malignancy. His introductory statement
ical status, location and size of the tumour, stage of was I have a painful ulceration on the tongue
the disease, lymph node status, several histopa- for 20 days now. When could you see me?
thological parameters, oncogene expression, pro- The standardised patient no. 2 (SP2) was a
liferation markers, ploidy pattern or response to 60 year-old male seeking prosthetic treatment.
treatment have been investigated as prognostic His introductory statement was I would like to
markers for oral cancer.5 Oral cancer diagnostic de- have some crown and bridgework done. When
lay has also been associated to advanced stages and could you see me?
poor prognosis.6 However, opportunistic screening In June 2002, each of these standardised pa-
by general dentistthe most logical group to screen tients asked for an appointment at 156 randomly
for oral canceris a significant step forward in the selected dental surgeries out of 700 registered with
efforts to decrease morbidity and mortality result- the Galician Dental Council. The variables consid-
ing from oral cancers.7,8 ered in the study were days to go until the arranged
Diagnostic delays in oral cancer have been clas- appointment, professional degree of the contacted
sified as patient delay or delay by patients person and referral to other provider of care.
(the period between the patient first consultation The data obtained from the interviews were en-
with a health professional concerning a symp- tered in a database (dBase IV) and analysed by
tom,915 and provider/professional delay or means of a statistical package (SPSS/PC+). A
delay by the clinicians (the period from the descriptive analysis was performed and the means
patients first consultation with a health care compared using a two factor ANOVA. The 95%
professional and the definitive pathological dia- confidence intervals were also determined.
gnosis).913 However, the simplicity of this classifi-
cation allows the recognition as delay by
patient the time elapsed until consultation due Results
to an inaccessibility to the provider of services9,16
and therefore the delay by patient is not always The standardised patient with lingual ulceration
due to the patients. To avoid this inconvenience, (SP1) telephoned to 156 dental surgeries demand-
the concept of scheduling delay (period be- ing attention for this problem. Five of them
tween the patient making an appointment and (3.2%) suggested he should better be seen at a hos-
actually seeing a health care professional) was pital. The other 151 arranged an appointment with-
introduced.17 in a time of 1 day. A 25% of the contacted offices
The influence of the accessibility (scheduling told the patient to go to the surgery the same
delay) to the health care system in oral cancer day. and the other 75% fixed an appointment within
diagnosis has not been studied before. a period of 65 days.
The aims of this study were to evaluate the When the standardised patient seeking fixed
scheduling delay in oral cancer diagnosis in dental prosthodontics (SP2) phoned to the allocated 156
surgeries in Galicia (Northwest of Spain) and to as- surgeries, the median delay for an appointment
sess the influence of the professional role of those was 6 days, and a 75% of the surgeries arranged
who allocate the appointment (receptionist vs gen- an appointment within a period of 613 days.
eral dental practitionerGDP) on this delay as a The mean time elapsed since the surgery was
baseline to determine the educational needs in this contacted until the patient would be actually seen
field. by a dental practitioner was significantly shorter
when the reason for attendance was an ulceration
suspicious of malignancy than when bridgework
Material and methods was demanded: 5.2 days vs 9.4 days ( X ei
X
ej
4:24; 95%CI =
6.22,
2.27).
To assess scheduling delay, a descriptive, cross- When the professional degree (receptionist vs
sectional study was designed. This study was based GDP) of the person arranging the appointment for
144 P.D. Dios et al.

Table 1 Scheduling delay by professional degree (GDPs vs receptionist)

Standardized patient Professional degree (n) e)
Mean ( X SD Median 25P 75P Range p
Ulceration (SP1) GDPs (33) 1.70 6.80 0.0 0.0 1.0 039 0.004*
Ulceration (SP1) Receptionist (118) 6.19 10.0 2.0 1.0 7.0 040
Prosthetics (SP2) GDPs (68) 8.18 7.5 6.0 4.0 12.0 034 0.07
Prosthetics (PS2) Receptionist (88) 10.44 8.11 8.0 5.0 14.0 031
SP = standardized patient; GDP = general dental practitioner; SD = standard deviation; 25P = 25%; 75P = 75%.
*
Statistically significant.

Figure 1 Scheduling delay by GDPs and receptionists in SP1 and SP2 patients.

the patient with lingual ulceration was considered, gate de-scheduling delay in lesions compatible
the scheduling delay was significantly shorter with oral cancer.
when the appointment fixed by the GDP ( X ei
Late diagnosis and delay in referral of oral can-
e j 4:5; 95%CI =
7.48,
1.51). However, this
X cer could be attributed to both patient and pro-
difference did not reach signification when the vider factors.22 Professional delay accounts for
patient prosthetic treatment ( X ei
X
e j 2:27; the time interval between the first visit to a health
95%CI =
4.7, 0.24) (Table 1). professional and the definitive diagnosis and re-
GDPs gave priority to the patients with lingual flects the delay in patients being referred to hospi-
ulcerations over those demanding fixed bridgework tal for confirmation by a histological diagnosis.10,23
ei
X
(X e j 6:48; 95%CI =
9.46,
3.50), as the Professional delay can result from failure on the
receptionist did, but with no statistical significa- part of the clinician to conduct a thorough exami-
ei
X
tion ( X e j 4:25; 95%CI =
6.81,
1.68) (Fig. nation, a low index of suspicion, and lack of expe-
1). rience with these tumours.24
Some differences have been identified between
dentists and physicians in terms of diagnostic pro-
files and perception of emergency in referring pa-
Discussion tients with oral cancer. Some reports indicated
that delay duration (advanced oral cancer associ-
Previous reports have used survey-type ques- ated with a delay in professional referral) was longer
tionnaires to evaluate the ability to diagnose and in patients referred by dentists than by physi-
make proper referral or oral and oropharingeal cians.6,25 In UK, a study of 96 cases of oral cancer
cancers.18,19 The tests of knowledge used in this demonstrated that family physicians were sig-
kind of investigations are surely important, but nificantly less likely to delay referral and more
they are also incomplete tools to assess compe- likely to make the correct diagnosis than
tence in a professional task.20 On the other hand, dentists.26 Paradoxically, other reports showed no
standardized patients with a structured script are significant association between the health care
an adequate instrument to evaluate practical abil- professional degree and the delay.12,27 However,
ities.21 We have used this methodology to investi- several reports support the emerging opinion
Scheduling delay in oral cancer diagnosis: a new protagonist 145

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