Survivorship and Patients Perspective
K. Antel1, C. Levetan, Z. Mohamed2, V. J. Louw1, J. Oosthuizen, E. Verburgh1
1 Division of Haematology, Department of Internal Medicine, University of Cape Town, 2 Department of Oncology, University of Cape Town
Introduction: The pathway to diagnosis of Hodgkin lymphoma (HL) has not been described in South Africa (SA) and is susceptible to delay due to the lack of distinct referral pathways for patients with lymphadenopathy, the poor diagnostic utility of fine-needle aspiration (FNA) in HL, and overlapping symptomatology with tuberculosis (TB) in a TB endemic zone. The aim of this paper was to determine the pathway to a diagnosis of HL and identify factors affecting time to diagnosis.
Methods: A cohort study of adult patients diagnosed with HL between Jan 2012-April 2014 and referred to a tertiary hospital in SA were included. Patients were interviewed regarding symptoms and health--seeking behaviour. Time intervals were divided into: Patient Interval (symptom onset to first healthcare consultation), Healthcare Practitioner Interval (HPI) (first healthcare to a diagnostic biopsy), Referral Interval (histological diagnosis to referral to the haematology clinic) and treatment interval (specialist clinic visit to treatment start date). Diagnostic delay was defined as a HPI >6wks. Multivariate logistic regression was performed to assess associations between clinically relevant covariates and delays in diagnosis.
Results: The median age of the 41 participants was 35; 66% had stage IV lymphoma and 44% were HIV+. The median total time to treatment was 149 days. The longest time interval was the healthcare practitioner interval with median time of 84 days. Median patient, referral and treatment intervals were 30, 14 and 21 days respectively. 73% of patients experienced diagnostic delay. 27% were on empiric TB treatment at the time of diagnosis, 59% had an FNA preceding diagnosis. Despite TB therapy and FNA requiring time in the pathway to diagnosis, in multivariate analysis they did not predict for diagnostic delay.
Conclusions: Healthcare practitioners are responsible for the longest time delay on the pathway to diagnosis of lymphoma. Poor access to biopsy service and healthcare practitioners attitudes are key factors in diagnostic delay. A high suspicion for TB lymphadenitis resulting in unnecessary time on TB therapy and an over estimation of the ability for FNA to diagnose lymphoma contribute to the length of the healthcare practitioner interval. Patient, referral and treatment intervals are similar to reported from Europe. Interventions targeting physician attitudes and providing a diagnostic biopsy service are critical to improve diagnostic time in lymphoma.