Pathways to diagnosis and treatment of head and neck cancer: outcomes and experiences of patients in NSW

Abstract

Delayed diagnosis and treatment of cancer can lead to poor outcomes. These relationships have not been well explored in Australia for head and neck cancer (HNC) patients. This thesis examines pathways to diagnosis and treatment of patients with HNC in New South Wales (NSW) with focus on the impact of remoteness of residence. Three primary studies were conducted. A retrospective cohort study reports on 224 patients treated for oropharyngeal or oral cavity cancer at two centres from 2008-2013. Regional patients had longer times to treatment and post-operative radiotherapy (PORT) compared to metropolitan patients. Guideline adherence for timely treatment was generally poor regardless of residence. In a prospective cohort study conducted from 2018 to 2020, quantitative data from 100 patients showed regional patients still experience longer times to treatment, however time to PORT appears to be improving. Health literacy negatively correlated with several pre-treatment intervals as well as care coordination. Qualitative data showed facilitators to early diagnosis and treatment included availability of services, social capital, and experience with the health system; barriers included travel/distance to services, lack of emotional investment from healthcare providers (HCP), and symptom appraisal/interpretation by HCPs. A survey of general practitioners (GPs) showed 42% of regional GPs expected a patient to be seen by a specialist within two weeks of referral compared to 70% of metropolitan GPs. Service availability was a driver of regional GPs’ decision of where to refer to, though metropolitan GPs perceived patients’ symptoms as the driving factor. Lastly, a narrative systematic review addresses the question of how health systems can be redesigned to address diagnostic and treatment intervals. In summary, the pathways to diagnosis and treatment of HNC are complex, requiring multidisciplinary and multi-system interventions to address disparities.