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Table of Contents
Year : 2020  |  Volume : 3  |  Issue : 4  |  Page : 798-800

How noteworthy is a delay in the diagnosis of childhood cancers?

1 Department of Pediatrics, Super Speciality Cancer Institute and Hospital, Lucknow, Uttar Pradesh, India
2 Department of Pediatrics, KGMU, Lucknow, Uttar Pradesh, India

Date of Submission19-Oct-2020
Date of Decision08-Nov-2020
Date of Acceptance11-Nov-2020
Date of Web Publication25-Dec-2020

Correspondence Address:
Nishant Verma
Department of Pediatrics, KGMU, Lucknow, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/crst.crst_330_20

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How to cite this article:
Pant G, Verma N. How noteworthy is a delay in the diagnosis of childhood cancers?. Cancer Res Stat Treat 2020;3:798-800

How to cite this URL:
Pant G, Verma N. How noteworthy is a delay in the diagnosis of childhood cancers?. Cancer Res Stat Treat [serial online] 2020 [cited 2021 Jan 26];3:798-800. Available from: https://www.crstonline.com/text.asp?2020/3/4/798/304997

The guilt regarding diagnostic delays in pediatric cancers has been bothering the primary physicians for the past four to five decades.[1] Whether the ball is in the physician's court or the parent's is a pertinent question that needs to be addressed. Moreover, whether this will translate to better survival outcomes is a matter of concern. With a significant number of childhood cancer cases being reported from India[2] and their relatively nonspecific signs and symptoms, these concerns need to be addressed adequately.

The article published by Singh et al. in the current issue of this journal helps us answer a few questions pertaining to the distribution and determinants of time to diagnosis in childhood cancers.[3] This cross-sectional study was conducted at the Kidwai Memorial Institute of Oncology in Karnataka, India between January and December 2019, in which pediatric patients aged<15 years with newly diagnosed solid tumors were included in the study. Prediagnostic time intervals were categorized as parent time (TP), time to referral (TR), and total time to diagnosis (TD). Among the 75 patients who were included in the study, the median TP, TR, and TD were 7, 43, and 76 days, respectively. TR was the most significant contributor to the TD, signifying the importance of sensitizing the primary care physicians and pediatricians to the early signs of childhood cancers. This will ensure that these patients are referred to specialized oncology centers in a timely manner. The time from symptom onset to first contact with a healthcare professional was significantly associated with maternal educational level and the type of solid tumor. The delay was more for tumors such as retinoblastoma and osteosarcoma and less for tumors such as hepatoblastoma and tumors of the brain. Another key point highlighted by the authors was the impact of distance between the place of residence and the cancer center on the time to diagnosis. The authors found that as the distance from the cancer center increased, the time to diagnosis also increased. This highlights the need for decentralization of cancer care and increasing the number of pediatric oncology care centers in the country.

The above data, though thorough, probably represent only the tip of the iceberg as patients who refused to take treatment, those lost to follow-up after registration, and those who died before a definitive diagnosis constituted nearly a third of the cohort and were excluded from the study. These groups of patients reveal the careless attitude of some of the parents toward the disease and could have contributed to the prolonged time to diagnosis. Moreover, the sample was not normally distributed, with the upper range for TD, TP, and TR reaching extremes along with a notable number of outliers in the box and whisker plot. This points toward a smaller sample size; perhaps a larger sample size would shift the median even further away. “Time to registration” which denotes the time gap between referral to an oncology center and registration at the center is something which is unique to low-and middle-income countries such as India where the entire responsibility of seeking care lies with the family of the patient.[4] Most previous studies on this subject have not looked at the “time to registration.” Although, the authors have mentioned the “time to registration” in their methodology and have included it as a component of “TP,” providing separate data on this time interval would have been interesting.

In a similar study done in our center in 2015 on 111 pediatric patients with cancer, we had also found that physician time also known as the referral interval was the most significant contributor to the time to diagnosis.[5] Tumor type and the use of alternative medicine significantly affected the TD in our study.[5] Brasme et al.[1] proposed that for most childhood tumors the time to diagnosis depends more on the tumor biology, and longer diagnostic delays do not necessarily translate to poorer outcomes. Although this is reassuring, it does not apply to all. Delayed diagnosis is associated with poorer outcomes for retinoblastoma and possibly for Wilms' tumor and rhabdomyosarcoma.[1]

The TD for retinoblastoma was reported to be 22 weeks, which is much longer than the 8-week TD reported by a recent systematic review by Brasme et al.[1] However, the percentage share of physician delay in the TD was 29% [Table 1] in this study which was comparable to that reported from the developed countries (23%). It is likely that the major chunk of diagnostic delay in retinoblastoma is contributed by the parents. Now the question arises regarding tackling such a situation. Leander et al.[6] described how teaching programs play a role in the downstaging of retinoblastoma, with more patients presenting with intraocular than with extraocular disease post the teaching campaign. In fact, retinoblastoma is the only pediatric malignant solid tumor till date that has shown such improved outcomes. Using this study as an example, we can also strengthen our system through community education of parents regarding the early identification of signs and symptoms and combining these teaching sessions with national vaccination programs. Television and radio bytes about the disease, interviews on national broadcasts, and posters and flyers with pictorial representation may also be helpful. Furthermore, these public awareness measures need to be ongoing rather than episodic, as their impact decreases with time.[7] Nowadays, even smartphone-based applications are available using which even non-ophthalmologists can make an early diagnosis of retinoblastoma without dilatation and anesthesia, and this can improve the diagnosis of the disease in the early stages.[8]
Table 1: Contribution of the various time lags for individual childhood tumor types

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Pediatric malignancies, at least those for which the survival outcomes improve with early diagnosis should be included in the national programs. Emphasis should be on the early detection of signs and symptoms by the healthcare workers at the grass-root level such as Anganwadi workers, community health officers, and Accredited Social Health Activists (ASHA). Cancer awareness measures for different types of pediatric cancers or a list of early warning signs might be helpful.[7] Apart from this, training the physicians in disease diagnosis; counseling parents reasonably and not alarming them about enucleation, amputation, and mutilating surgeries; and highlighting the high cure rates of childhood cancers should be stressed upon. Finally, the establishment of dedicated pediatric oncology centers with multimodal therapists cannot be better emphasized.

Diagnostic delays contributing to the poor overall survival should be studied in further detail for all pediatric malignancies as there is a deficiency of data from India,[9] where the culture and traditions, illiteracy, poverty, politics, and logistics are added factors that affect this lag phase significantly. This study and other studies from India[3],[10] have elucidated the magnitude and determinants of delays in the diagnosis of childhood cancer in the country. However, to study the impact of these delays, longitudinal studies with follow-up and outcome data are needed in the future.

Apart from the parents and physicians, another 'P' that is continuously delaying the treatment nowadays is the “pandemic.[11]” New patient registrations during the coronavirus disease 2019 pandemic and the associated “lockdown” dropped significantly across all the cancer centers.[12] As the lockdown was eased, majority of the patients with solid tumors that presented to us had locally advanced or metastatic disease.

In conclusion, physician delay or delay in referral is the biggest hindrance for timely management of childhood cancers in low-and middle-income countries such as India. There is an urgent need to train the healthcare providers at all levels to help in the early recognition of cancer symptoms. To enable prompt referral, network, and referral pathways need to be established with the help of various government and non-government organizations.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Brasme JF, Morfouace M, Grill J, Martinot A, Amalberti R, Bons-Letouzey C, et al. Delays in diagnosis of paediatric cancers: A systematic review and comparison with expert testimony in lawsuits. Lancet Oncol 2012;13:e445-59.  Back to cited text no. 1
Arora RS, Eden TO, Kapoor G. Epidemiology of childhood cancer in India. Indian J Cancer 2009;46:264-73.  Back to cited text no. 2
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Singh S, Kumar A, Kumar N, Kaushik PS, Akkineni V, Appaji L. First symptom and time to diagnosis in pediatric patients with solid tumors: A cross-sectional study from a regional cancer institute in south India. Cancer Res Stat Treat 2020;3:716-23.  Back to cited text no. 3
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Philip CC, Mathew A, John M J. Cancer care: Challenges in the developing world. Cancer Res Stat Treat 2018;1:58-62.  Back to cited text no. 4
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Verma N, Bhattacharya S. Time to diagnosis and treatment of childhood cancer. Indian J Pediatr 2020;87:641-3.  Back to cited text no. 5
Leander C, Fu LC, Peña A, Howard SC, Rodriguez-Galindo C, Wilimas JA, et al. Impact of an education program on late diagnosis of retinoblastoma in Honduras. Pediatr Blood Cancer 2007;49:817-9.  Back to cited text no. 6
Poyiadjis S, Wainwright L, Naidu G, Mackinnon D, Poole J. The Saint Siluan warning signs of cancer in children: Impact of education in rural South Africa. Pediatr Blood Cancer 2011;56:314-6.  Back to cited text no. 7
Khedekar A, Devarajan B, Ramasamy K, Muthukkaruppan V, Kim U. Smartphone-based application improves the detection of retinoblastoma. Eye (Lond) 2019;33:896-901.  Back to cited text no. 8
Noronha V. Making a case for cancer research in India. Cancer Res Stat Treat 2018;1:71-4.  Back to cited text no. 9
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Kulkarni KP, Marwaha RK. Symptom diagnosis interval in childhood acute lymphoblastic leukemia: Prognostic impact and association with clinico-demographic factors. Indian J Med Paediatr Oncol 2012;33:188.  Back to cited text no. 10
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Pande P, Sharma P, Goyal D, Kulkarni T, Rane S, Mahajan A. COVID-19: A review of the ongoing pandemic. Cancer Res Stat Treat 2020;3:221-32.  Back to cited text no. 11
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Bansal S, Dolendo M, Hoa Nguyen TK, Sharma K. Survival of children with cancers amidst COVID-19: A fight with two enemies. Cancer Res Stat Treat 2020;3:281-3.  Back to cited text no. 12
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