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Evaluation of delays in diagnosis and treatment of childhood malignancies in Bangladesh

Introduction: Malignancy is one of the leading causes of morbidity and mortality worldwide. According to GLOBOCAN 2012, an estimated 14.1 million new cancer cases and 8.2 million cancer-related deaths occurred in 2012. It is estimated that childhood malignancies are 0.5–4.6% of total malignancies. However, from the point of view of potential year lost due to childhood malignancies, it is more important than adult. Materials and Methods: To find out the probable components for the delay in diagnosis and treatment of childhood malignancies in Bangladesh, cross-sectional observational study was done at the National Institute of Cancer Research and Hospital, Dhaka, Bangladesh, from January 2014 to June 2014. Results: A total of 171 patients were included in the study. They were divided into four age groups. The mean age was 8.422 years with standard deviation ± 5.381 years and their age ranged from 2 months to 18 years. In aggregate, about 70% of the cases had to wait for more than 90 days for the treatment. About 15% had to wait for 31–60 days. Negligible percentage of patients got treatment before 30 days. Among the three components of delay, patients delay was influenced by age of the child, economic status of the family, parental education, and awareness of the parents about malignancy. Conclusion: More than one-third of the pediatric patients had to wait three months or more for treatment to start for various reasons. By raising awareness among the stake holders this problem can be minimized. Further studies are recommended to explore the other factors which might cause delayed referral.


Introduction
Malignancy is one of the leading causes of morbidity and mortality worldwide. In 2012, 14.1 million new cancer cases occurred globally and childhood cancer was 0.5-4.6% of total malignancies. [1] According to the registry of Pediatric Oncology Department of National Institute of Cancer Research and Hospital (NICRH), 1440 new cases of childhood malignancies attended the department during January 2008 to December 2013. Early diagnosis of childhood malignancies is often difficult because of nonspecific symptom in most cases. Diagnosis delays prevent timely treatment and cause unnecessary complications. Long delays in diagnosis had negative effect on prognosis. [2,3] Causes of delays can be grouped into three categories: patient and/or parent delay, diagnosis and/or doctor delay, and treatment delay.

Materials and Methods
This was a cross-sectional study conducted on diagnosed cancer patients aged ≤18 years of both genders at NICRH. A total of 171 patients were enrolled in the study. The protocol was approved by the Institute's Ethics Committee. Informed written consents were obtained from each guardian before data collection. Data were collected by face-to-face interviews of the guardians using a pretested questionnaire. The first prescription was collected as evidence of 1 st contact with physician to calculate patient delay. Data were then checked, entered, and analyzed using SPSS for Windows (IBM SPSS Statistics for Windows, version 17.0, Armonk, NY: IBM Corp). Qualitative data were analyzed using  2 test and continuous data by t-test. P ≤ 0.05 was considered statistically significant at 95% confidence level.

Results
The mean age was 8.42 (standard deviation ± 5.381) years. Most of the patients (122/171) were male. In 53.8% cases, patients delay was <30 days. In more than half of the cases, doctors' delay   money a month took their children to a physician more early then the families with lesser income (P < 0.05) [ Table 2].

Discussion
Lack of health insurance system, guardians' perceptions of illness, misinterpretation of early symptoms, poor access to health care facilities, and competing other responsibilities are the causes of patient delay. Delay is usually a relative term. Considering our present socioeconomic situation, we considered 30 days as a cutoff point as delays in the different stages. In our study, children <2 years of age had to wait less than older children which was statistically significant. Younger children may experience malignancy with more identifiable signs at onset than older children. It is consistent with the study that showed association between age and delay. [4] On average, the female child had to wait more days to consult a doctor than the boy. Statistically significant difference was noted between the families regarding monthly income. Previous knowledge on childhood malignancy influences the patient delay. Those parents who heard about the childhood malignancy beforehand were more prompt to seek treatment for their child. The influence of increased parent knowledge and awareness of the child's disease on timely diagnosis is also supported by the finding of a negative association between father's education and diagnosis delay. These findings are supported by the study. [5] Other studies showed no advantage with higher education of parents. [6,7] About 70% of the cases had to wait for more than 3 months for the treatment. In our study, delays were influenced by the child's age, family's socioeconomic status, father's education, and knowledge about childhood malignancies. Awareness about childhood malignancy in the society and in the healthcare provider can solve this problem.
Our study has some limitations. It was a small sized single-center study. Another limitation was accuracy of the information of initial onset of symptoms, and exact time of appearance of first symptoms depends on the memory of the parents. Thus, recall bias was a problem.