Delay in diagnosis and treatment of patients with oral cancer seeking treatment in a public tertiary hospital in India

Delay in diagnosis and treatment of patients with oral cancer seeking treatment in a public tertiary hospital in India | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Delay in diagnosis and treatment of patients with oral cancer seeking treatment in a public tertiary hospital in India Parth Sharma, Mongjam Meghachandra Singh, Amod Laxmikant Borle, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6318005/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction : The burden of oral cancer is rising, especially in the Indian subcontinent, which contributes one-third of all global cases. Oral cancer, though preventable, often goes undetected until later stages. There is a paucity of literature on the duration of patient, diagnostic, and treatment intervals for oral cancer management in India. The study aimed to estimate the patient, diagnostic, and treatment intervals for oral cancer patients and to explore factors contributing to delays. Methods: This cross-sectional mixed-method study was conducted at Lok Nayak Hospital in Delhi. The study included 116 patients with histopathologically confirmed oral cancer in the quantitative survey and 11 in the qualitative in-depth interviews who were receiving treatment within the last three months. Purposive sampling was used for both the quantitative survey and qualitative interviews. Statistical analysis was performed using SPSS, while qualitative data were manually coded to identify themes. The ‘Aarhus statement’ guidelines were followed in designing and reporting the study. Results: The study population had a mean age of 48 years, with a majority being male (87.9%), and Hindu (66.4%), half were from lower socioeconomic groups (50%) and 65.5% presented with Stage IV disease. The median patient interval was 13.5 (5.0, 59.5) days, the diagnostic interval was 88.0 (39.0, 218.2) days, and the treatment interval was 54.5 (28.8, 92.5) days, with a total median interval of 194.5 (133.5, 427.5) days. Delays were mainly due to symptoms being dismissed as minor (98.2%), initial healthcare worker not suspecting cancer (50.0%) and pre-treatment investigation delays (19.8%). Key qualitative barriers included poor healthcare access (especially in rural areas), lack of awareness of symptom severity, reliance on self-medication, and family-related distractions. Delayed recognition by initial healthcare providers contributed to further delays. Family structure and advice by the first heart care provider significantly influenced diagnostic interval. Conclusion: A majority of the patients with oral cancer presented with advanced-stage disease with diagnostic interval being the longest followed by treatment and patient intervals. Future studies should study interventions to reduce these delays and also assess the impact of these delays on the disease outcome. 1. Introduction In 2021, cancer was the third leading cause of death globally and the fourth leading cause of death in India ( 1 ). Globally, nearly 19.3 million people are diagnosed with cancer every year ( 2 ). In 2020, nearly half of the new cases and 58.3% of the cancer-related deaths occurred in Asia where 59.5% of the global population resides ( 2 ). In India, nearly 15 lakh people are diagnosed with cancer every year. In India, these cancers' incidence will rise to 20 lakh per annum by 2040 ( 3 ). In 2020, in men, oral cancer was the leading cancer type ( 4 ). Oral and oropharyngeal cancers (henceforth, both will be referred to together as ‘oral cancer’) are preventable diseases with several risk factors. The commonest risk factors for oral cancer are tobacco use, alcohol consumption, infection with the HPV virus, chronic inflammation, and genetic predisposition ( 5 ). However, despite being a preventable cancer that can also be diagnosed at an early precancerous stage, the burden of oral cancer has been rising globally. It is the sixth most common cancer in males accounting globally for 377,713 new cases and 177,757 deaths in 2020, increasing from 354,864 new cases and 177,384 deaths in 2018 ( 6 ). The highest burden of oral cancer is in the Indian subcontinent with India contributing one-third of all oral cancer cases ( 7 ). In India, oral cancer incidence has also risen over the years. Within India also a regional distribution of oral cancer has been noticed with the highest burden being present in the northeastern part of the country ( 8 ). It is well known that the prognosis of oral cancer progressively worsens as the stage at diagnosis progresses ( 9 ). However, as per the National Cancer Registry Program Report 2020, nearly two-thirds of the patients with oral cancer in India were diagnosed with advanced-stage disease ( 8 ). Diagnosis at an advanced stage could be attributed to delays in symptom appraisal, help-seeking, diagnosis, and/or initiation of treatment ( 10 ). As it is inappropriate to blame the patient for these delays the World Health Organization (WHO) has suggested the term “Patient interval” rather than “Patient delay” ( 11 ). Multiple studies have been conducted to measure and understand the reasons for these intervals. However, they have lacked uniformity in their definitions and approaches. This has made comparison across these studies difficult. To tackle this, the “Aarhus statement” was developed by early cancer researchers which consists of definitions and recommendations for early cancer diagnosis research ( 12 ). There is a paucity of literature to understand the reasons for patient, diagnostic, and treatment intervals in oral cancer patients in India. As the only previously done study using the Aarhus statement was from Kerala, a high-income state with high literacy levels, the results cannot be generalized to the rest of the country ( 13 ). This creates a knowledge gap in guiding policy interventions for cancer prevention. This study aimed to estimate the various intervals associated with the diagnosis and treatment of oral or oropharyngeal cancer and identify factors associated with the intervals for patients seeking treatment from a tertiary care public hospital in Delhi. 2. Methods 2.1 Study design and setting This was a cross-sectional mixed-methods study consisting of a quantitative survey followed by qualitative in-depth interviews. The study was registered on the Clinical Trials Registry – India on 19th July 2023 (CTRI registration number: CTRI/2023/07/055360). The study was done in the Lok Nayak Hospital, a teaching tertiary care setting hospital affiliated with Maulana Azad Medical College in Delhi from November 2023 to May 2024. The hospital is a referral center for cancer treatment in the north Indian region. 2.2 Study population Patients above 18 years of age with a histopathological confirmed diagnosis of oral cancer and who had initiated treatment within the past 3 months were included in the study. The cancers of the following anatomical structures in the oral cavity and oropharynx were considered: lip, base, surface, and border of the tongue, gum, the floor of the mouth, hard palate, soft palate, buccal mucosa, uvula, pharyngeal walls, and tonsils. Severely ill patients (viz. patients in severe pain unable to talk, patients in need of urgent admission, or patients admitted in intensive care units), and patients with a history of cancer of other body parts, or with recurrence of oral cancer were excluded from the study. Patients who experienced more than 3 months of total treatment delay were selected for in-depth interviews. 2.3 Sample size and sampling method The following formula was used for calculating the sample size of the quantitative survey: $$\:N={Z}^{2}\frac{pq}{{d}^{2}}$$ The following values were used: Z = 1.96, Value of the standard normal variate corresponding to the level of significance, α = 5%, Prevalence of patient interval of more than 3 months (13) (p) = 54%, and q = 100-p = 46% Absolute precision (d) = 9% Therefore, the sample size for the quantitative survey was calculated to be 116. The sample size for the in-depth interview was taken to be 20 participants or until data saturation was reached, whichever was lesser. Purposive sampling was used to collect data from oral cancer patients at ENT and Radiotherapy OPDs/IPDs. Every alternate patient who presented consecutively was approached, and if they declined, the next patient was recruited after obtaining informed consent. 2.4 Data collection A pretested interview schedule was used to gather the information from the participants. The schedule was created using a literature review and expert consultation. It was pretested on 10 people for face validity. Necessary modifications were made before finalizing the tool. Written informed consent was taken from all individuals willing to participate in the study. 2.4.1 Quantitative data collection Data on the patient interval, diagnostic interval, and treatment interval and factors contributing to these intervals were collected in a direct patient interview using the pre-tested interview schedule. The participants were interviewed in the OPD, IPD, or daycare. Pseudo-exact dates were chosen using a protocol with estimated dates based on the patient's history (14). Time points like the date of biopsy, date of biopsy report, patient registration number, and disease stage information were collected from the patient case files. The data was collected using EpiCollect5 software. 2.4.2 Qualitative data collection In-depth interviews were recorded and to maintain confidentiality personal details of participants from the audio recordings were removed and they were anonymized. The interview guide used was related to the patient’s journey from the onset of symptoms to the start of treatment. This included the patient’s reasons for a delay in the identification of symptoms, the delay in seeking care, and the difficulties the patient faced till the diagnosis of oral cancer was reached and treatment for the same was started. The interview guide was translated into Hindi and re-translated to English to check for consistency. 2.5 Operational definitions Definitions of the following time points were based on the ‘phases of clinical pathway' described by Olesen et al (2009) (15). 1. Date of the first symptom: Self-reported date on which a patient identified a bodily change or symptom in the oral cavity. This was estimated using a pre-defined protocol. 2. Date of the first presentation: The date on which the patient consulted a health care provider (doctor of modern medicine and others) to discuss the bodily change or symptom in the oral cavity, based on available records or patient recall. 3. Date of diagnosis: The date of diagnosis was decided based on a hierarchy produced by the European Network of Cancer Registries in the order of declining priority: a. Date of first histological or cytological confirmation of this malignancy (except histology or cytology at autopsy). This date was, in the following order: (a) the date when the specimen was taken (biopsy) (b) the date of receipt by the pathologist (c) the date of the pathology report b. Date of admission to the hospital because of this malignancy. c. When evaluated at an outpatient clinic only: date of first consultation at the outpatient clinic because of this malignancy. 4. Patient interval: The period between the ‘Date of the first symptom' to the ‘Date of the first presentation'. 5. Diagnostic interval: The period between the ‘Date of the first presentation' to the ‘Date of diagnosis'. 6. Treatment interval: The period between the ‘Date of the diagnosis’ to ‘Date of initiation of treatment.’ 2.6 Statistical analysis 2.6.1 Quantitative data Descriptive statistical methods were used to summarize categorical and continuous variables. Mean and standard deviation (SD) was used for variables with a Gaussian distribution and median and interquartile range (IQR) for variables with a skewed distribution. The cut-off for per capita family income was decided based on the poverty line income cutoff for the urban Delhi population for 2023-24 (16). The updated Modified Kuppuswamy Scale for 2024 was used to assess socioeconomic status (17). Univariate analyses were carried out using the Mann-Whitney U test when two groups were present and the Kruskal-Wallis test when more than two groups were present. Significance levels were defined at 0.05. All analysis was done in SPSS Ver 25.0. 2.6.2 Qualitative data The interviews were transcribed in Hindi and then translated into English following which thematic analysis was conducted. To analyze the in-depth interviews, a coding scheme was developed based on the themes emerging from the data to examine the challenges faced by patients in completing the diagnostic process and starting treatment across different healthcare settings in the Indian health system. The coding was done manually. The themes identified were summarized and supported with quotes from the patients. 3. Results 3.1 Sociodemographic characteristics and disease profile of participants The mean age of the study population was 47.9 ± 11.1 years. The majority were male (87.9%), Hindu (66.4%), belonged to the General caste category (67.3%) and were married (86.2%). Educationally, 39 (33.6%) were illiterate and 86 (74.1%) lived in nuclear families. The majority were residents of Delhi (54.3%). The per capita family income revealed a median income of Rs 1464, with an interquartile range (IQR) from Rs 0 to Rs 2500 with 36 (31.0%) families having no monthly income. A majority were unemployed (89.7%), and belonged to the upper lower or lower socioeconomic class (97.4%) (Table 1 ). Tobacco use was prevalent in the study population, with 63 (54.3%) using smokeless tobacco, 12 (10.3%) using smoked forms of tobacco, 32 (27.6%) using both smoked and smokeless forms and 9 (7.8%) giving history of never consuming tobacco. Out of those who smoked tobacco (N = 107), 100 (93.3%) smoked bidis and only 7 (6.7%) smoked cigarettes. The median (IQR) pack years smoked were 5.5 (1.9–8.8) years. For alcohol, 60 (51.7%) reported use, with 48.3% (n = 56) never drinking. Table 1 Sociodemographic characteristics of the study population (N = 116) Variable Frequency (%) Age (Mean ± SD) 47.9 ± 11.1 Gender Male 102 (87.9) Female 14 (12.1) Religion Hindu 77 (66.4) Muslim 37 (31.9) Sikh 2 (1.7) Category of caste General 78 (67.3) Other Backward Castes 23 (19.8) Scheduled Castes 15 (12.9) Marital status Married 100 (86.2) Unmarried 6 (5.2) Widowed 7 (6.0) Divorced 2 (1.7) Separated 1 (0.9) Education Illiterate 39 (33.6) Primary school 15 (12.9) Middle school 25 (21.6) High school 23 (19.8) Inter/Diploma 12 (10.4) Graduation 2 (1.7) Per capita family income (Median and IQR) Median (IQR) 1464 (0-2500) Minimum - Maximum 0-25000 Present occupation of the patient Clerical, shop-owner, farmer 2 (1.7) Skilled worker 6 (5.1) Semi-skilled 3 (2.6) Unskilled worker 1 (0.9) Unemployed 104 (89.7) Socioeconomic status as per Modified Kuppuswamy Scale (2024) Lower middle 3 (2.6) Upper lower 55 (47.4) Lower 58 (50.0) Type of family Nuclear 86 (74.1) Joint 30 (25.9) Place of residence Delhi 63 (54.3) Uttar Pradesh 40 (34.5) Bihar 5 (4.3) Others 8 (6.9) The most common site of cancer was the buccal mucosa (38.8%), followed by the tongue (31.9%) and the alveolus (11.2%). Other sites of cancer included hard palate, soft palate, and tonsillar fossa. All cases were confirmed as squamous cell carcinoma on histopathological examination. Most tumors were moderately differentiated (59.5%), with 42 (36.2%) classified as well-differentiated and 5 (4.3%) as poorly differentiated. The T stage distribution showed that 62 (53.4%) were classified as T4, while 7 (6.0%) were T1. For the N stage, 33 (28.4%) were N0, and 37 (31.9%) were N2. Metastasis was present in 4 (3.4%) of cases (M1), while 112 (96.6%) were M0. The TNM staging revealed that 76 (65.5%), 28 (24.2%), 8 (6.9%) and 4 participants (3.4%) were diagnosed with Stages IV, III, II and I cancer respectively. 3.2 Patient, healthcare worker, and health system-related factors in oral cancer diagnosis and treatment Patient-related factors In response to the first symptom, 54 (46.6%) consulted a doctor, while 22 (18.9%) attributed the symptom to a minor issue and waited for it to resolve. Additionally, 17 (14.7%) self-medicated, and 14 (12.1%) tried home remedies. Most participants (81.9%) shared their symptom onset with a family member. The majority of these family members were spouses (50.0%), followed by sons/daughters (22.4%). When advising the patient, 71.6% suggested consulting a doctor, while only a small number advised self-medication (2.6%), using home remedies (4.3%), or stopping tobacco use (0.9%). Healthcare worker-related factors Study participants saw a median of 2 healthcare providers (IQR = 1–4) before being diagnosed, with a range of 0 to 25 providers. Cancer was first suspected by the first healthcare provider for 50 (43.1%) participants while for 34.5% of the participants, it took a visit to more than two healthcare providers for cancer to be first suspected. The specialization of the first doctor seen included dental specialists (31.0%), followed by informal medical providers (23.4%), general practitioners (19.8%), ENT specialists (19.8%), cancer specialists (2.6%), and others (3.4%). Advice given by the first healthcare provider varied, with 64 (55.2%) attributing the symptom as minor and advising follow-up. Meanwhile, 26 (22.4%) provided symptomatic treatment and advised a biopsy and another 26 (22.4%) offered symptomatic treatment and referred the patient to a higher center. Health system-related factors A total of 44 (37.9%) participants took more than 120 minutes from their homes to reach the hospital where they were seeking treatment. Additionally, 27 (23.3%) traveled between 31 to 60 minutes and 23 (19.9%) between 61 to 120 minutes. Only 7 (6.0%) reached in less than 15 minutes. The public bus was the most common mode of transport, used by 60 (51.7%) of participants. Other modes included taxis (23.3%, n = 27/116), intercity trains plus taxis (12.1%), and own vehicles (6.0%, n = 7/116), with local trains being the least preferred (4.3%). 3.3 Patient, diagnostic, and treatment interval durations The median (IQR) duration of the patient interval was 13.5 (5.0, 59.5) days, the diagnostic interval was 88.0 (39.0, 218.2) days and the treatment interval was 54.5 (28.8, 92.5) days. The total interval, combining all phases, had a median (IQR) of 194.5 (133.5, 427.5) days. 3.3 Factors associated with patient, diagnostic, and treatment intervals Among the sociodemographic factors, the type of family was significantly associated with the diagnostic interval with the median diagnostic interval being higher in patients belonging to nuclear families (p = 0.013) ( Supplementary Table 1) . The median diagnostic interval was more than double for females compared to males, and the median treatment interval was nearly 1.5 times that of people above 60 years of age for people less than 60 years of age. Similarly, the median diagnostic interval was longer for patients who were illiterate and who were single, divorced, widowed, or separated when compared with patients who were literate and married with a living spouse, respectively. However, these differences were not statistically significant (p < 0.05). Among health system-related factors, the diagnostic interval was significantly longer if the first healthcare provider gave symptomatic treatment and did not refer the patient (p < 0.001) ( Supplementary Table 2 ). The diagnostic interval was longer when cancer was first suspected after the patient had consulted at least two healthcare providers (p < 0.05). However, the treatment interval was significantly longer for patients where cancer was suspected by either the first or second healthcare provider (p = 0.020). The patient, diagnostic, and treatment intervals were longer for patients using public transport as compared to those renting vehicles, taxis, or using private vehicles. However, these differences were not statistically significant (p < 0.05). The grade and stage of the disease were not significantly associated with patient, diagnostic and treatment intervals ( Supplementary Table 3 ). 3.4 Reasons for delay in diagnosis and treatment of oral cancer 3.4.1 Quantitative survey findings Patient interval A significant majority, 114 (98.2%), attributed their delay to considering their symptoms as minor and waiting for them to subside. Other reasons included being too busy to make time for a doctor (3.7%) and concerns about the costs of consulting a doctor or visiting a hospital (2.7%). Additional factors cited were the lack of an accompanying person to visit the hospital (0.9%) and worries about prescribed tests (0.9%). Other reasons, including fear of cancer and disbelief in allopathic treatments, were less common, with each noted by only one participant (Table 2 ). Table 2 Reason for seeking delay in healthcare after identification of symptom (patient interval) (N = 116) Reason* Frequency (%) Found it difficult to get an appointment with a particular doctor. 1 (0.9) Too busy to make time to go to the doctor. 4 (3.7) Had too many other things to worry about. 1 (0.9) Worried about tests prescribed by doctors. 1 (0.9) Did not have an accompanying person to visit the hospital. 1 (0.9) Attributed symptoms as minor and waited for them symptoms to subside 114 (98.2) Did not have money to consult a doctor/visit a hospital 3 (2.7) Did not believe in Allopathic medicines and treatment and preferred alternative medicines 1 (0.9) Afraid of cancer and delayed seeing the doctor 1 (0.9) Believed care is not curable 2 (1.8) Did not share my symptoms with the family as they would get worried 1 (0.9) *Not mutually exclusive Diagnostic interval The primary reason cited was that the initial healthcare provider did not suspect cancer, reported by 58 (50.0%) of participants. Financial constraints also played a role, with 18 (15.5%) unable to afford timely tests and another 18 (15.5%) delaying biopsy due to initial symptom relief from symptomatic treatment. Additional reasons included difficulty in reaching facilities with biopsy testing available (8.6%), long waiting times for tests (8.6%), and concerns about the biopsy procedure (4.3%). Notably, 23 (19.8%) of participants felt that their diagnosis was not delayed, highlighting varied perceptions of the diagnostic timeline (Table 3 ). Table 3 Reason for delay in diagnosis after seeing a healthcare provider (diagnostic interval) (N = 116) Reason Frequency (%) The initial healthcare provider did not suspect cancer 58 (50.0) Found it difficult to reach the facility with biopsy testing available 10 (8.6) Did not have money to get the tests done on time 18 (15.5) Did not have the time to get the tests done 6 (5.2) Was afraid of confirming the diagnosis of cancer 3 (2.6) Was afraid of the biopsy procedure 5 (4.3) The waiting time for tests to get done was long 10 (8.6) Delayed biopsy due to initial relief of symptoms with symptomatic treatment 18 (15.5) Delayed biopsy hoping the symptoms would subside on their own 1 (0.9) Delayed biopsy to seek other opinions on the problem 4 (3.4) False negative biopsy on initial evaluation 11 (9.5) COVID lockdown delayed biopsy 1 (0.9) Sickness of another person in the family 3 (2.6) Did not feel that diagnosis was delayed 23 (19.8) Treatment interval A notable 48 (41.4%) of participants felt that their treatment was not delayed. Among those who experienced delays, the most common reasons included lengthy pre-treatment investigations after biopsy (19.8%) and difficulty in obtaining timely appointments for cancer treatment (14.6%). Financial barriers also affected treatment initiation, with 9 (7.8%) unable to afford cancer treatment. Other reasons included delays due to uncontrolled chronic diseases (6.9%) and opting for alternative forms of treatment (5.1%) (Table 4 ). Table 4 Reasons for delay in initiation of treatment following diagnosis of oral cancer (treatment interval) (N = 116) Reason Frequency (%) Opted for alternate forms of treatment 6 (5.1) Was afraid of cancer treatment – chemotherapy/surgery/radiation 4 (3.4) Found it difficult to reach a center with cancer treatment 1 (0.9) Did not have money for cancer treatment 9 (7.8) Did not have time to start cancer treatment 2 (1.7) Another acute illness delayed treatment 5 (4.3) Other uncontrolled chronic disease delayed cancer treatment 8 (6.9) Found it difficult to get a timely appointment for cancer treatment 17 (14.6) Pre-treatment investigations following biopsy took time 23 (19.8) Other personal reasons 6 (5.1) Did not feel that treatment was delayed 48 (41.4) 3.4.2 Qualitative findings A total of 11 patients with oral cancer were interviewed following which saturation of themes was achieved. Supplementary Table 4 presents the sociodemographic and disease characteristics of study participants who underwent in-depth interviews. The mean (SD) age of the participants was 53.5 (10.5) years. The group consisted of 7 males and 4 females. Educational attainment varied, with 4 participants being illiterate, 4 having completed high school, and 2 holding graduate degrees. Out of the 11 participants, 9 participants were Hindu, while 2 were Muslim. The majority (8 participants) were at Stage IV. The grades of differentiation included poorly differentiated (2 participants), moderately differentiated (5 participants), and well-differentiated (4 participants). The median patient interval was 31.0 days, with an interquartile range (IQR) of 3.0 to 92.0 days. The diagnostic interval had a median of 176.0 days and an IQR of 80.0 to 304.0 days. For the treatment interval, the median was 46.0 days, accompanied by an IQR of 26.0 to 46.0 days. Lastly, the total interval showed a median of 233.0 days, with an IQR of 166.0 to 594.0 days. The themes identified for delay in seeking care, getting diagnosed, and starting treatment are listed in Table 5 . Table 5 Themes identified for patient, diagnostic, and treatment interval through qualitative interviews (N = 11) Type of interval Theme Patient interval Poor access to healthcare Lack of awareness in the patient Lack of support to go to the hospital Initial improvement of symptoms due to self-medication with over-the-counter medications Other family events requiring urgent attention Diagnostic and Treatment interval Lack of awareness among healthcare providers and patients Lack of time due to job Financial constraints and lack of government facilities for treatment Delay in treatment due to non-availability of early appointment for investigations Lack of patient navigation system at hospitals Delay due to poor access to treatment centers and overcrowded public health centers Patient interval: 1. Poor access to healthcare: Participants expressed their struggles with accessing medical care, often due to geographical barriers. Lack of cancer treatment facilities in their hometown, lack of access to transport, and long travel time to the nearest health center affected early health seeking. "There was no doctor in our village. We had to travel 2 hours to the city to show a doctor." - P3 2. Lack of awareness in the patient: Patients commonly also reported that they would have sought early care had they known that the initial symptom was due to cancer. For some, misinformation and myths regarding the initial symptom also led to a delay in seeking care. Patients therefore sought care only when the symptoms worsened. "I had tooth pain. Some people told me not to get the tooth extracted as it would lead to blindness." - P2 "Initially I had only an ulcer and when the problem progressively increased, I went to a local informal provider." - P10 3. Lack of support to go to the hospital: People living in rural areas and the elderly also found it difficult to access healthcare as there was nobody to accompany them to the hospital. "I was in the village and my son was working in the city. There was no one living with me in the village who could take me to the hospital" - P4 4. Initial improvement of symptoms due to self-medication with over-the-counter medications: Due to poor access to trained healthcare professionals, for their initial symptoms of ulcer and pain, patients often bought over-the-counter medications. The initial relief in symptoms due to self-medication also contributed to a delay in health seeking from trained professionals. "The pain resolved when I took painkillers and so I was not worried. I took painkillers for 3 months." - P2 5. Other family events requiring urgent attention - A patient mentioned a delay in seeking care due to other events in the family that required urgent attention. In the words of P1: "A relative died in my family. I had to go there and so could not see the doctor as soon as the pain started." Diagnostic and treatment interval 1. Lack of awareness among healthcare providers and patients: Patients reported that the initial healthcare provider, both formal and informal practitioners, they saw for their complaints did not suspect cancer. As the patients themselves were also not aware, they did not consider the symptoms to be significant. This delayed the diagnosis of the cancer. Due to a lack of awareness, the informal providers also contributed to the delay in diagnosis and treatment by delaying referral to trained healthcare providers. Another patient (P8) said, "The doctor I saw in the beginning gave an ointment following which I had partial relief in symptoms. The doctor did not tell me to go to a bigger hospital. I came here by myself when my condition worsened. If the doctor had told me that this was an ulcer and if does not improve after a few days then get checked in a bigger hospital then my treatment would have started early." "The doctor kept giving treatment and said that he would cure it. We showed another doctor and asked him if this was cancer. I had seen a person with cancer before so I had an intuition. But the doctor said it is not what I was thinking and that the ulcer will heal." - P9 Often symptomatic treatment given by the first healthcare provider led to an improvement in symptoms which also led to delay as the patient considered the symptoms to be benign. "The first doctor I showed gave me some medications that improved my symptoms. However, the symptoms did not settle after 3 months. The doctor then advised a CT scan and referred to Delhi." - P3 On the contrary, early suspicion from a doctor helped a patient seek care sooner. "The first doctor we saw directly told us that this is cancer and we need to go to a bigger hospital to start treatment." - P6 2. Lack of time due to a job - A patient reported that as he could not take leave from his work, he kept getting symptomatic treatment from local informal providers and delayed seeking care from a trained practitioner. In the words of P11, "I used to get paid on a daily basis and so showed local informal doctors as it took less time and I could avoid taking leave.” 3. Financial constraints and lack of government facilities for treatment: Financial constraints also led to a delay in early diagnosis and initiation of treatment as the cost of diagnostic tests and treatment was unaffordable in the private hospitals and the same services were either inaccessible or not available in the public hospitals. "The ENT doctor took Rs 400 fees and told me I did not have any problem. He advised tests for Rs 6000 and I did not get them done as they were too expensive." - P2 4. Lack of patient navigation system at hospitals: Patients reported that the treatment was delayed as the tests couldn’t be done on time. The reason for the delay in tests was that the patient and caregivers did not know where the tests had to be done in the hospital. "The investigations took time as it was not clearly conveyed which forms and whose signatures were needed for the tests to be done under the Delhi government's scheme. If all the information was conveyed together the tests would have taken less time and treatment would have started early." - P4 5. Delay in treatment due to non-availability of early appointments for investigations - Patients reported that after getting the diagnosis confirmed through biopsy, treatment was delayed because of the tests that had to be done before starting treatment. Various blood investigations and imaging tests took time because of which treatment could not be started as soon as the patient was diagnosed with cancer. In the words of P2 - "There was a delay in starting treatment as investigations took too much time. We were asked to get a CT scan done but the earliest appointment was after 5 months in the hospital." 6. Delay due to poor access to treatment centers and overcrowded public health centers: Even after getting diagnosed early and getting all tests done, patients reported delays in the initiation of treatment due to the non-availability of early treatment appointments in government hospitals. Poor referral mechanisms within government hospitals also contributed to delays. This has been corroborated by the following response from the participant: "The treatment started in X hospital but they did not have radiation therapy. They referred me here but this hospital refused to give radiation therapy as chemotherapy was given in a different hospital. I had to do multiple rounds of both hospitals and after 2 to 3 months radiation therapy started." - P7 4. Discussion The study examined various intervals in patient care for oral cancer, revealing significant delays in diagnosis and treatment. The diagnostic interval (median = 88.0 days) was found to be the longest followed by the treatment (median = 54.5 days) and patient intervals (median = 13.5 days). Overall, the total interval, combining all phases, had a median of 194.5 days. A cancer treatment center in Maharashtra classified delays in care into primary, secondary, and tertiary delays. The primary delay, from symptom onset to visiting a primary care physician, was the longest at 2.75 months. Secondary delay, from seeking advice to referral to a tertiary center, was 1.94 months, while tertiary delay, from referral to the start of treatment, was 1.4 months ( 18 ). A study by Swaminathan et al. (2024) examined diagnostic delays and the impact of various patient and tumor factors on these delays. The study interviewed 120 patients and found that the median primary delay was 90 days, while the median secondary delay was 11 days ( 19 ). While the diagnostic interval was comparable to existing literature from India, the patient interval was significantly shorter in our study population. This could be due to easy access to informal healthcare providers and pharmacies, both of which were also considered to be a part of the healthcare system in this study to assess the delay caused due to them. The first healthcare provider suspected cancer in 43.1% of cases, with dental specialists being the most common initial contact (31.0%). This was in contrast to the study by Rath et al (2018) where only 7% of the patients first met a dentist ( 20 ). Upon seeking care, patients visited an average of two healthcare providers before receiving a diagnosis. Initial advice varied, with 55.2% of providers dismissing the symptoms as minor, 22.4% recommending a biopsy, and another 22.4% referring the patient to a higher center. Most patients (98.2%) attributed delays to considering their symptoms minor and waiting for them to resolve. Other reasons for delay included being too busy (3.7%) or concerns about the costs of care (2.7%). The qualitative findings from the in-depth interviews revealed several key factors contributing to delays in seeking care and receiving timely diagnosis and treatment for cancer. Poor access to healthcare, especially in rural areas, was a major barrier to timely care. Patients often traveled long distances to medical centers, while others delayed seeking help due to a lack of awareness or attributed their symptoms to less serious causes. Elderly patients and those living alone struggled to access care without family support, and self-medication delayed proper treatment. Similar reasons for delay were reported by Rath et al (2018), for example, lack of awareness, hope that the lesion will heal spontaneously, lack of perception of seriousness, and financial constraints ( 20 ). After consulting healthcare providers, 50.0% of patients reported delays in diagnosis because the initial provider did not suspect cancer, while financial barriers (15.5%) and delays in biopsy procedures (15.5%) were also common factors. The in-depth interviews revealed that diagnostic delays were linked to a lack of awareness among both patients and healthcare providers. Many initial consultations did not recognize cancer symptoms, leading to prolonged treatment for less serious conditions. Financial constraints, including the high cost of tests and treatment, further delayed care, especially in areas lacking affordable government services. In 2014, Akram et al, in Uttar Pradesh, reported significant risk factors contributing to delays in seeking hospital care included older age, low socioeconomic status, rural residence, lack of awareness about head and neck cancer, downplaying of symptoms as minor, absence of fear, and reliance on alternative therapies ( 21 ). Once diagnosed, 41.4% of participants felt their treatment was not delayed, but among those who experienced delays, the most common reasons included lengthy pre-treatment investigations (19.8%), difficulty scheduling cancer treatment appointments (14.6%), and financial constraints (7.8%). Other delays were linked to chronic health conditions (6.9%) or opting for alternative treatments (5.1%). In-depth interviews revealed that the system-level issues, such as long waiting times for tests and a lack of coordinated referrals, added further delays once patients sought care. These logistical and financial barriers contributed to prolonged intervals between diagnosis and treatment, potentially affecting patient outcomes. The analysis of factors associated with the patient interval identified a few trends, although they did not reach statistical significance. For example, the type of transportation to healthcare facilities showed a tendency where those using public transport had a longer patient interval (15.0 days) compared to those using private or rented transport (8.0 days, p = 0.486). This trend could reflect differences in the accessibility and speed of care, though further research would be necessary to confirm their significance. Despite these trends, most other factors, including demographic characteristics (age, gender, education), did not show meaningful associations with patient intervals. In a 2024 study by Swaminathan et al, education was reported to play a significant role in literate patients presenting earlier for treatment ( 19 ). However, a similar finding was not seen in this study. In a study by Bayable et al (2023) in Ethiopia variables such as being female, rural residence, low social support, not having any other comorbidity and poor awareness were associated with delayed health seeking ( 22 ). Similar to this study, a study by Bhatia et al (2018) in Botswana reported that patients living with larger families were less likely to experience a help-seeking delay for cancer ( 23 ). Family structure was found to significantly influence the diagnostic delay, with patients from nuclear families experiencing a longer median diagnostic interval (101.0 days) compared to those from joint families (49.5 days) (p = 0.013). Additionally, patients who received symptomatic treatment without referral had a significantly longer median diagnostic interval of 119.5 days, compared to those referred to a higher center, whose median interval was 47.5 days (p < 0.001). Gender showed a trend toward significance, with females reporting longer diagnostic intervals (198.0 days vs. 86.0 days for males) (p = 0.067). Other sociodemographic factors, including age, education, marital status, and socioeconomic status, did not show significant associations with diagnostic intervals. These findings suggest that family structure and the referral process are important determinants of diagnostic intervals, while other factors, such as gender, require further exploration. In a study by Poum et al (2014), significant associations were reported between delay in breast cancer diagnosis and education, family income, time to referral, and number of consultations with a surgeon before diagnosis ( 24 ). The findings of a systematic review in 2021 by Lima et al suggested that a lack of awareness about the signs and symptoms of oral cancer, along with the undervaluation of self-care, are strongly linked to delays in its diagnosis ( 25 ). Older patients (60 years and above) had a median treatment interval of 35.5 days, slightly shorter than the 56.5 days for those under 60, but this difference was not statistically significant (p = 0.180). Similarly, while males had a median treatment interval of 55.5 days and females had 46.0 days, the difference was also not significant (p = 0.796). Literature on factors associated with treatment delay in patients with oral cancer is lacking from India, however, a study by Saka-Herran et al in 2021 reported that patients with advanced-stage disease, primary treatment with radiotherapy, treatment at an academic facility, and transitions in care were associated with prolonged pre-treatment intervals ( 26 ). Policy recommendations To reduce time taken for diagnosis and treatment of oral cancer, interventions are necessary to reduce all three intervals, i.e., patient, diagnostic and treatment. Increasing awareness of the general population regarding harmful effects of tobacco, increasing coverage population-based screening, improving access to primary health care and promoting health seeking behaviour will help in reducing patient interval. Increasing awareness regarding presentation of oral cancer in healthcare providers, improving access to and availability of diagnostic services with the use of digital health or hub and spoke model of healthcare, covering expense of diagnostic services in government funded insurance schemes and addressing cancer related stigma in the community will help in reducing the diagnostic interval in oral cancer management. Lastly, improving access to cancer treatment by establishing government funded cancer treatment centers, especially in rural parts of the country and providing insurance coverage and access to social security schemes to protect the family from financial toxicity of the disease will help in reducing the treatment interval in oral cancer management. Strengths and limitations This is the first study to assess all three levels of intervals - patient, diagnostic, and treatment - in patients with oral cancer in India. This study was conducted in a referral public health center for cancer treatment which sees footfall of people from the middle and lower socioeconomic populations in India in which oral cancer is commonly seen. Therefore, the findings represent the struggles faced by a majority of the people who are diagnosed with oral cancer. Being a mixed methods study, the qualitative part of the study helped in identifying reasons for delays that were missed in the quantitative survey. However, despite these strengths, the study has a few limitations. First, since the date of symptom identification was based on memory recall there is a possibility of a recall bias. However, a pseudo-exact date method was used to identify the most accurate date of symptom identification which might not be exact. Second, due to a relatively small sample size, the number of women included in the study was small, and therefore the gender disparity in seeking treatment could not be extensively studied. However, the reported trend highlighted that woman took longer to be diagnosed than men. This trend requires further investigation. Third, the pathways to treatment were based on patient recall and could not be verified using medical records in most patients. Fourth, the study included only participants from public health centers, and patients from private health centers could not be enrolled. Therefore, the findings cannot be generalized to private-sector hospitals. Lastly, being a cross-sectional study, the association of delay on the overall survival of patients could not be studied in this study. 5. Conclusion A majority of the patients with oral cancer presented in advanced stage disease with preventable delays at various levels. The diagnostic interval was found to be the longest followed by treatment and patient interval. There are various risk factors predisposing people to these delays. There is a need to increase awareness regarding the harmful effects of tobacco along with an improvement in access to tobacco cessation services. There is also a need for screening in high risk population for oral cancer along with improvement in awareness regarding early symptoms of oral cancer both in healthcare providers and patients. Future studies should study the impact of these delays on the survival of the patients and assess interventions that reduce these delays. Declarations Conflict of interest: None Ethics approval and consent to participate Ethics clearance was taken from the Institutional Ethical Committee (F.1/IEC/MAMC/MD/MS(96/02/2023/No.125) on 15.05.2023. Consent for publication Not applicable. Availability of data and materials All data will be available on reasonable request to the corresponding author. Competing interests The authors declare that they have no competing interests Funding This study did not receive any funding. Authors' contributions PS – Conceptualization, Data Collection, Data Analysis, Data interpretation, Manuscript – Original Draft wiritng MMS – Conceptualization, Data interpretation, Manuscript – Review and Editing, Supervision ALB - Conceptualization, Data interpretation, Manuscript – Review and Editing AS - Conceptualization, Data interpretation, Manuscript – Review and Editing RM - Conceptualization, Data interpretation, Manuscript – Review and Editing Acknowledgements The author (PS) would like to thank Dr Nandini Sharma, ex-Dead, Maulana Azad Medical College for her constant support and guidance. References Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet Lond Engl. 2020 Oct 17;396(10258):1204–22. Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin. 2021;71(3):209–49. Sathishkumar K, Chaturvedi M, Das P, Stephen S, Mathur P. Cancer incidence estimates for 2022 & projection for 2025: Result from National Cancer Registry Programme, India. Indian J Med Res. 2022;156(4 & 5):598–607. Ferlay J, Colombet M, Soerjomataram I, Parkin DM, Piñeros M, Znaor A, et al. Cancer statistics for the year 2020: An overview. Int J Cancer. 2021;149(4):778–89. Irani S. New Insights into Oral Cancer—Risk Factors and Prevention: A Review of Literature. Int J Prev Med. 2020 Dec 30;11:202. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018 Nov;68(6):394–424. Borse V, Konwar AN, Buragohain P. Oral cancer diagnosis and perspectives in India. Sens Int. 2020;1:100046. Factsheet - National Cancer Registry Programme (ICMR-NCDIR) [Internet] Bengaluru, India [cited 2024 Nov 23] Available from : https://ncdirindia.org/All_Reports/Report_2020/Factsheet/Fact_Sheet_2020.pdf Sciubba JJ. Oral cancer. The importance of early diagnosis and treatment. Am J Clin Dermatol. 2001;2(4):239–51. Scott SE, Walter FM, Webster A, Sutton S, Emery J. The Model of Pathways to Treatment: Conceptualization and integration with existing theory. Br J Health Psychol. 2013;18(1):45–65. World Health Organization. Guide to cancer early diagnosis [Internet]. Geneva: World Health Organization; 2017 [cited 2023 Jan 2]. 48 p. Available from: https://apps.who.int/iris/handle/10665/254500 Weller D, Vedsted P, Rubin G, Walter FM, Emery J, Scott S, et al. The Aarhus statement: improving design and reporting of studies on early cancer diagnosis. Br J Cancer. 2012 Mar;106(7):1262–7. Philip PM, Kannan S. Patient Interval and Associated Factors in the Diagnostic Journey of Oral Cancer: A Hospital-Based Cross-Sectional Study from Kerala, India. Asian Pac J Cancer Prev APJCP. 2021 Oct;22(10):3143–9. Philip PM, Kannan S. Tool development and validation of the oral cancer patient and diagnostic interval measure. Int J Community Med Public Health. 2022 Jan 28;9(2):819–25. Olesen F, Hansen RP, Vedsted P. Delay in diagnosis: the experience in Denmark. Br J Cancer. 2009 Dec 3;101 Suppl 2(Suppl 2):S5-8. Planning Department, Government of National Capital Territory of Delhi. Poverty line in Delhi 2023-24 [Internet]. Delhi, India [cited 2024 Nov 23]. Available from: https://delhiplanning.delhi.gov.in/sites/default/files/Planning/20._poverty_line.pdf Javalkar SR, H S, Davalagi SB, S VG. Socio economic status assessment in India: history and updates for 2024. Int J Community Med Public Health. 2024 Feb 29;11(3):1369–77. Joshi P, Nair S, Chaturvedi P, Nair D, Agarwal JP, D′Cruz AK. Delay in seeking specialized care for oral cancers: Experience from a tertiary cancer center. Indian J Cancer. 2014 Jun;51(2):95. Swaminathan D, George NA, Thomas S, Iype EM. Factors associated with delay in diagnosis of oral cancers. Cancer Treat Res Commun. 2024;40:100831. Rath H, Shah S, Sharma G, Mishra E. Exploring determinants of care-seeking behaviour of oral cancer patients in India: A qualitative content analysis. Cancer Epidemiol. 2018 Apr 1;53:141–8. Akram M, Siddiqui SA, Karimi AM. Patient Related Factors Associated with Delayed Reporting in Oral Cavity and Oropharyngeal Cancer. Int J Prev Med. 2014 Jul;5(7):915–9. Bayable A, Tegenaw A, Tesfaye Z, Lidetu T, Assefa A, Dessie G. Delay in health-seeking behaviour and associated factors among adult patients with cancer in Ethiopia: a multicentre cross-sectional study. BMJ Open. 2023 Aug 29;13(8):e071406. Bhatia RK, Rayne S, Rate W, Bakwenabatsile L, Monare B, Anakwenze C, et al. Patient Factors Associated With Delays in Obtaining Cancer Care in Botswana. J Glob Oncol. 2018 Aug;4:1–13. Poum A, Promthet S, Duffy SW, Parkin DM. Factors associated with delayed diagnosis of breast cancer in northeast Thailand. J Epidemiol. 2014;24(2):102–8. Lima AM da C, Meira IA, Soares MSM, Bonan PRF, Mélo CB, Piagge CSLD. Delay in diagnosis of oral cancer: a systematic review. Med Oral Patol Oral Cir Bucal. 2021 Nov;26(6):e815–24. Varela-Centelles P, Seoane J, Lopez-Cedrun J l., Fernandez-Sanroman J, García-Martin J m., Takkouche B, et al. The length of patient and primary care time interval in the pathways to treatment in symptomatic oral cancer. A quantitative systematic review. Clin Otolaryngol. 2018;43(1):164–71. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6318005","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":436149213,"identity":"a6fa25da-06e9-4f71-818f-6ce8875f30f7","order_by":0,"name":"Parth Sharma","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBElEQVRIiWNgGAWjYJACZiBOALM+/rEBkoyNBwjoYGyGaWGc2ZAGohqI18LM23AYLIRXizn72eePCxjq8vhnn078wLvjvN3a9sNAW2psonFpsexJN2yewXC4WOJc7mYJyTO3k7edSQRqOZaW24BDi8GBNMZmHoYDiQ1neDdIGLDdTjYDsg8wNhzGreX8M5CWusT5Z3g3/0hgO5dsdv4hAS03wLYwJ244w7tN4mDbATuzGwRssZzxjHE2j8HhxI1ALZYNZ5ITzG4AbUnA4xdz/jSGzzwVdYnzgA67/afCzt7sfPrDBx9qbHA7DIkEg0SwygQcytEUQ4A9HsWjYBSMglEwQgEApCtm/U0IrZUAAAAASUVORK5CYII=","orcid":"","institution":"Maulana Azad Medical College","correspondingAuthor":true,"prefix":"","firstName":"Parth","middleName":"","lastName":"Sharma","suffix":""},{"id":436149214,"identity":"284da451-76fa-4e10-ab82-9a9b06885a9a","order_by":1,"name":"Mongjam Meghachandra Singh","email":"","orcid":"","institution":"Maulana Azad Medical College","correspondingAuthor":false,"prefix":"","firstName":"Mongjam","middleName":"Meghachandra","lastName":"Singh","suffix":""},{"id":436149215,"identity":"db464bdd-13d8-4208-be8c-1a9db54e3bba","order_by":2,"name":"Amod Laxmikant Borle","email":"","orcid":"","institution":"Maulana Azad Medical College","correspondingAuthor":false,"prefix":"","firstName":"Amod","middleName":"Laxmikant","lastName":"Borle","suffix":""},{"id":436149216,"identity":"b87c3156-9cb5-4d72-879d-152e2a69d7f5","order_by":3,"name":"Anurita Srivastava","email":"","orcid":"","institution":"Maulana Azad Medical College","correspondingAuthor":false,"prefix":"","firstName":"Anurita","middleName":"","lastName":"Srivastava","suffix":""},{"id":436149217,"identity":"91e831e3-3505-4b17-acc2-04ecd09dfb36","order_by":4,"name":"Ravi Meher","email":"","orcid":"","institution":"Maulana Azad Medical College","correspondingAuthor":false,"prefix":"","firstName":"Ravi","middleName":"","lastName":"Meher","suffix":""}],"badges":[],"createdAt":"2025-03-27 07:38:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6318005/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6318005/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":79646637,"identity":"7a5cc705-eb0a-4112-bc1d-5ad4c3e9088a","added_by":"auto","created_at":"2025-04-01 07:10:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1137466,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6318005/v1/067a6fd2-abd4-4329-9374-79e3efd89eda.pdf"},{"id":79644520,"identity":"b60e7492-d42f-4f4c-b383-671e5056d92f","added_by":"auto","created_at":"2025-04-01 06:46:33","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":18894,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarytable.docx","url":"https://assets-eu.researchsquare.com/files/rs-6318005/v1/9ee081f54bee3aca768532b1.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Delay in diagnosis and treatment of patients with oral cancer seeking treatment in a public tertiary hospital in India","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eIn 2021, cancer was the third leading cause of death globally and the fourth leading cause of death in India (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Globally, nearly 19.3\u0026nbsp;million people are diagnosed with cancer every year (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). In 2020, nearly half of the new cases and 58.3% of the cancer-related deaths occurred in Asia where 59.5% of the global population resides (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). In India, nearly 15 lakh people are diagnosed with cancer every year. In India, these cancers' incidence will rise to 20 lakh per annum by 2040 (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). In 2020, in men, oral cancer was the leading cancer type (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOral and oropharyngeal cancers (henceforth, both will be referred to together as \u0026lsquo;oral cancer\u0026rsquo;) are preventable diseases with several risk factors. The commonest risk factors for oral cancer are tobacco use, alcohol consumption, infection with the HPV virus, chronic inflammation, and genetic predisposition (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). However, despite being a preventable cancer that can also be diagnosed at an early precancerous stage, the burden of oral cancer has been rising globally. It is the sixth most common cancer in males accounting globally for 377,713 new cases and 177,757 deaths in 2020, increasing from 354,864 new cases and 177,384 deaths in 2018 (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). The highest burden of oral cancer is in the Indian subcontinent with India contributing one-third of all oral cancer cases (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). In India, oral cancer incidence has also risen over the years. Within India also a regional distribution of oral cancer has been noticed with the highest burden being present in the northeastern part of the country (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIt is well known that the prognosis of oral cancer progressively worsens as the stage at diagnosis progresses (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). However, as per the National Cancer Registry Program Report 2020, nearly two-thirds of the patients with oral cancer in India were diagnosed with advanced-stage disease (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Diagnosis at an advanced stage could be attributed to delays in symptom appraisal, help-seeking, diagnosis, and/or initiation of treatment (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAs it is inappropriate to blame the patient for these delays the World Health Organization (WHO) has suggested the term \u0026ldquo;Patient interval\u0026rdquo; rather than \u0026ldquo;Patient delay\u0026rdquo; (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Multiple studies have been conducted to measure and understand the reasons for these intervals. However, they have lacked uniformity in their definitions and approaches. This has made comparison across these studies difficult. To tackle this, the \u0026ldquo;Aarhus statement\u0026rdquo; was developed by early cancer researchers which consists of definitions and recommendations for early cancer diagnosis research (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThere is a paucity of literature to understand the reasons for patient, diagnostic, and treatment intervals in oral cancer patients in India. As the only previously done study using the Aarhus statement was from Kerala, a high-income state with high literacy levels, the results cannot be generalized to the rest of the country (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). This creates a knowledge gap in guiding policy interventions for cancer prevention. This study aimed to estimate the various intervals associated with the diagnosis and treatment of oral or oropharyngeal cancer and identify factors associated with the intervals for patients seeking treatment from a tertiary care public hospital in Delhi.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\"\u003e\n \u003ch2\u003e2.1 Study design and setting\u003c/h2\u003e\n \u003cp\u003eThis was a cross-sectional mixed-methods study consisting of a quantitative survey followed by qualitative in-depth interviews. The study was registered on the Clinical Trials Registry – India on 19th July 2023 (CTRI registration number: CTRI/2023/07/055360).\u003c/p\u003e\n \u003cp\u003eThe study was done in the Lok Nayak Hospital, a teaching tertiary care setting hospital affiliated with Maulana Azad Medical College in Delhi from November 2023 to May 2024. The hospital is a referral center for cancer treatment in the north Indian region.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\"\u003e\n \u003ch2\u003e2.2 Study population\u003c/h2\u003e\n \u003cp\u003ePatients above 18 years of age with a histopathological confirmed diagnosis of oral cancer and who had initiated treatment within the past 3 months were included in the study. The cancers of the following anatomical structures in the oral cavity and oropharynx were considered: lip, base, surface, and border of the tongue, gum, the floor of the mouth, hard palate, soft palate, buccal mucosa, uvula, pharyngeal walls, and tonsils. Severely ill patients (viz. patients in severe pain unable to talk, patients in need of urgent admission, or patients admitted in intensive care units), and patients with a history of cancer of other body parts, or with recurrence of oral cancer were excluded from the study. Patients who experienced more than 3 months of total treatment delay were selected for in-depth interviews.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\"\u003e\n \u003ch2\u003e2.3 Sample size and sampling method\u003c/h2\u003e\n \u003cp\u003eThe following formula was used for calculating the sample size of the quantitative survey:\u003c/p\u003e\n \u003cdiv id=\"Equa\"\u003e\n \u003cdiv id=\"FileID_Equa\" name=\"EquationSource\"\u003e$$\\:N={Z}^{2}\\frac{pq}{{d}^{2}}$$\u003c/div\u003e\n \u003c/div\u003e\n \u003cp\u003eThe following values were used:\u003c/p\u003e\n \u003cp\u003eZ = 1.96, Value of the standard normal variate corresponding to the level of significance, α = 5%,\u003c/p\u003e\n \u003cp\u003ePrevalence of patient interval of more than 3 months (13) (p) = 54%, and q = 100-p = 46%\u003c/p\u003e\n \u003cp\u003eAbsolute precision (d) = 9%\u003c/p\u003e\n \u003cp\u003eTherefore, the sample size for the quantitative survey was calculated to be 116. The sample size for the in-depth interview was taken to be 20 participants or until data saturation was reached, whichever was lesser.\u003c/p\u003e\n \u003cp\u003ePurposive sampling was used to collect data from oral cancer patients at ENT and Radiotherapy OPDs/IPDs. Every alternate patient who presented consecutively was approached, and if they declined, the next patient was recruited after obtaining informed consent.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\"\u003e\n \u003ch2\u003e2.4 Data collection\u003c/h2\u003e\n \u003cp\u003eA pretested interview schedule was used to gather the information from the participants. The schedule was created using a literature review and expert consultation. It was pretested on 10 people for face validity. Necessary modifications were made before finalizing the tool. Written informed consent was taken from all individuals willing to participate in the study.\u003c/p\u003e\n \u003cdiv id=\"Sec7\"\u003e\n \u003ch2\u003e2.4.1 Quantitative data collection\u003c/h2\u003e\n \u003cp\u003eData on the patient interval, diagnostic interval, and treatment interval and factors contributing to these intervals were collected in a direct patient interview using the pre-tested interview schedule. The participants were interviewed in the OPD, IPD, or daycare. Pseudo-exact dates were chosen using a protocol with estimated dates based on the patient's history (14). Time points like the date of biopsy, date of biopsy report, patient registration number, and disease stage information were collected from the patient case files. The data was collected using EpiCollect5 software.\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec8\"\u003e\n \u003ch2\u003e2.4.2 Qualitative data collection\u003c/h2\u003e\n \u003cp\u003eIn-depth interviews were recorded and to maintain confidentiality personal details of participants from the audio recordings were removed and they were anonymized. The interview guide used was related to the patient’s journey from the onset of symptoms to the start of treatment. This included the patient’s reasons for a delay in the identification of symptoms, the delay in seeking care, and the difficulties the patient faced till the diagnosis of oral cancer was reached and treatment for the same was started. The interview guide was translated into Hindi and re-translated to English to check for consistency.\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\"\u003e\n \u003ch2\u003e2.5 Operational definitions\u003c/h2\u003e\n \u003cp\u003eDefinitions of the following time points were based on the ‘phases of clinical pathway' described by Olesen et al (2009) (15).\u003c/p\u003e\n \u003cp\u003e1.\u0026nbsp; \u0026nbsp;Date of the first symptom: Self-reported date on which a patient identified a bodily change or symptom in the oral cavity. This was estimated using a pre-defined protocol.\u003c/p\u003e\n \u003cp\u003e2.\u0026nbsp; \u0026nbsp;Date of the first presentation: The date on which the patient consulted a health care provider (doctor of modern medicine and others) to discuss the bodily change or symptom in the oral cavity, based on available records or patient recall.\u003c/p\u003e\n \u003cp\u003e3.\u0026nbsp; \u0026nbsp;Date of diagnosis: The date of diagnosis was decided based on a hierarchy produced by the European Network of Cancer Registries in the order of declining priority:\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ea.\u0026nbsp; \u0026nbsp;Date of first histological or cytological confirmation of this malignancy (except histology or cytology at autopsy). This date was, in the following order: (a) the date when the specimen was taken (biopsy) (b) the date of receipt by the pathologist (c) the date of the pathology report\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eb.\u0026nbsp; \u0026nbsp;Date of admission to the hospital because of this malignancy.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ec.\u0026nbsp; \u0026nbsp;When evaluated at an outpatient clinic only: date of first consultation at the outpatient clinic because of this malignancy.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4. Patient interval: The period between the ‘Date of the first symptom' to the ‘Date of the first presentation'.\u003c/p\u003e\n \u003cp\u003e5. Diagnostic interval: The period between the ‘Date of the first presentation' to the ‘Date of diagnosis'.\u003c/p\u003e6. Treatment interval: The period between the ‘Date of the diagnosis’ to ‘Date of initiation of treatment.’\n\u003c/div\u003e\n\u003cdiv id=\"Sec10\"\u003e\n \u003ch2\u003e2.6 Statistical analysis\u003c/h2\u003e\n \u003cdiv id=\"Sec11\"\u003e\n \u003ch2\u003e2.6.1 Quantitative data\u003c/h2\u003e\n \u003cp\u003eDescriptive statistical methods were used to summarize categorical and continuous variables. Mean and standard deviation (SD) was used for variables with a Gaussian distribution and median and interquartile range (IQR) for variables with a skewed distribution. The cut-off for per capita family income was decided based on the poverty line income cutoff for the urban Delhi population for 2023-24 (16). The updated Modified Kuppuswamy Scale for 2024 was used to assess socioeconomic status (17). Univariate analyses were carried out using the Mann-Whitney U test when two groups were present and the Kruskal-Wallis test when more than two groups were present. Significance levels were defined at 0.05. All analysis was done in SPSS Ver 25.0.\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec12\"\u003e\n \u003ch2\u003e2.6.2 Qualitative data\u003c/h2\u003e\n \u003cp\u003eThe interviews were transcribed in Hindi and then translated into English following which thematic analysis was conducted. To analyze the in-depth interviews, a coding scheme was developed based on the themes emerging from the data to examine the challenges faced by patients in completing the diagnostic process and starting treatment across different healthcare settings in the Indian health system. The coding was done manually. The themes identified were summarized and supported with quotes from the patients.\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Sociodemographic characteristics and disease profile of participants\u003c/h2\u003e \u003cp\u003eThe mean age of the study population was 47.9\u0026thinsp;\u0026plusmn;\u0026thinsp;11.1 years. The majority were male (87.9%), Hindu (66.4%), belonged to the General caste category (67.3%) and were married (86.2%). Educationally, 39 (33.6%) were illiterate and 86 (74.1%) lived in nuclear families. The majority were residents of Delhi (54.3%). The per capita family income revealed a median income of Rs 1464, with an interquartile range (IQR) from Rs 0 to Rs 2500 with 36 (31.0%) families having no monthly income. A majority were unemployed (89.7%), and belonged to the upper lower or lower socioeconomic class (97.4%) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Tobacco use was prevalent in the study population, with 63 (54.3%) using smokeless tobacco, 12 (10.3%) using smoked forms of tobacco, 32 (27.6%) using both smoked and smokeless forms and 9 (7.8%) giving history of never consuming tobacco. Out of those who smoked tobacco (N\u0026thinsp;=\u0026thinsp;107), 100 (93.3%) smoked bidis and only 7 (6.7%) smoked cigarettes. The median (IQR) pack years smoked were 5.5 (1.9\u0026ndash;8.8) years. For alcohol, 60 (51.7%) reported use, with 48.3% (n\u0026thinsp;=\u0026thinsp;56) never drinking.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSociodemographic characteristics of the study population (N\u0026thinsp;=\u0026thinsp;116)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (Mean\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47.9\u0026thinsp;\u0026plusmn;\u0026thinsp;11.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e102 (87.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (12.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eReligion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHindu\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e77 (66.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMuslim\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37 (31.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSikh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (1.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eCategory of caste\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGeneral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78 (67.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther Backward Castes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (19.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eScheduled Castes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (12.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eMarital status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100 (86.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnmarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (5.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWidowed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (6.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDivorced\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (1.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSeparated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003eEducation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIlliterate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39 (33.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (12.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMiddle school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (21.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (19.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInter/Diploma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (10.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGraduation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (1.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePer capita family income (Median and IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedian (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1464 (0-2500)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMinimum - Maximum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0-25000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003ePresent occupation of the patient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClerical, shop-owner, farmer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (1.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSkilled worker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (5.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSemi-skilled\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (2.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnskilled worker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e104 (89.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eSocioeconomic status as per Modified Kuppuswamy Scale (2024)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLower middle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (2.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUpper lower\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55 (47.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLower\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58 (50.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eType of family\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNuclear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e86 (74.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJoint\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (25.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003ePlace of residence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDelhi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63 (54.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUttar Pradesh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40 (34.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBihar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (4.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (6.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe most common site of cancer was the buccal mucosa (38.8%), followed by the tongue (31.9%) and the alveolus (11.2%). Other sites of cancer included hard palate, soft palate, and tonsillar fossa. All cases were confirmed as squamous cell carcinoma on histopathological examination. Most tumors were moderately differentiated (59.5%), with 42 (36.2%) classified as well-differentiated and 5 (4.3%) as poorly differentiated. The T stage distribution showed that 62 (53.4%) were classified as T4, while 7 (6.0%) were T1. For the N stage, 33 (28.4%) were N0, and 37 (31.9%) were N2. Metastasis was present in 4 (3.4%) of cases (M1), while 112 (96.6%) were M0. The TNM staging revealed that 76 (65.5%), 28 (24.2%), 8 (6.9%) and 4 participants (3.4%) were diagnosed with Stages IV, III, II and I cancer respectively.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Patient, healthcare worker, and health system-related factors in oral cancer diagnosis and treatment\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003ePatient-related factors\u003c/strong\u003e \u003cp\u003eIn response to the first symptom, 54 (46.6%) consulted a doctor, while 22 (18.9%) attributed the symptom to a minor issue and waited for it to resolve. Additionally, 17 (14.7%) self-medicated, and 14 (12.1%) tried home remedies. Most participants (81.9%) shared their symptom onset with a family member. The majority of these family members were spouses (50.0%), followed by sons/daughters (22.4%). When advising the patient, 71.6% suggested consulting a doctor, while only a small number advised self-medication (2.6%), using home remedies (4.3%), or stopping tobacco use (0.9%).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eHealthcare worker-related factors\u003c/strong\u003e \u003cp\u003eStudy participants saw a median of 2 healthcare providers (IQR\u0026thinsp;=\u0026thinsp;1\u0026ndash;4) before being diagnosed, with a range of 0 to 25 providers. Cancer was first suspected by the first healthcare provider for 50 (43.1%) participants while for 34.5% of the participants, it took a visit to more than two healthcare providers for cancer to be first suspected. The specialization of the first doctor seen included dental specialists (31.0%), followed by informal medical providers (23.4%), general practitioners (19.8%), ENT specialists (19.8%), cancer specialists (2.6%), and others (3.4%). Advice given by the first healthcare provider varied, with 64 (55.2%) attributing the symptom as minor and advising follow-up. Meanwhile, 26 (22.4%) provided symptomatic treatment and advised a biopsy and another 26 (22.4%) offered symptomatic treatment and referred the patient to a higher center.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eHealth system-related factors\u003c/strong\u003e \u003cp\u003eA total of 44 (37.9%) participants took more than 120 minutes from their homes to reach the hospital where they were seeking treatment. Additionally, 27 (23.3%) traveled between 31 to 60 minutes and 23 (19.9%) between 61 to 120 minutes. Only 7 (6.0%) reached in less than 15 minutes. The public bus was the most common mode of transport, used by 60 (51.7%) of participants. Other modes included taxis (23.3%, n\u0026thinsp;=\u0026thinsp;27/116), intercity trains plus taxis (12.1%), and own vehicles (6.0%, n\u0026thinsp;=\u0026thinsp;7/116), with local trains being the least preferred (4.3%).\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Patient, diagnostic, and treatment interval durations\u003c/h2\u003e \u003cp\u003eThe median (IQR) duration of the patient interval was 13.5 (5.0, 59.5) days, the diagnostic interval was 88.0 (39.0, 218.2) days and the treatment interval was 54.5 (28.8, 92.5) days. The total interval, combining all phases, had a median (IQR) of 194.5 (133.5, 427.5) days.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Factors associated with patient, diagnostic, and treatment intervals\u003c/h2\u003e \u003cp\u003eAmong the sociodemographic factors, the type of family was significantly associated with the diagnostic interval with the median diagnostic interval being higher in patients belonging to nuclear families (p\u0026thinsp;=\u0026thinsp;0.013) (\u003cb\u003eSupplementary Table\u0026nbsp;1)\u003c/b\u003e. The median diagnostic interval was more than double for females compared to males, and the median treatment interval was nearly 1.5 times that of people above 60 years of age for people less than 60 years of age. Similarly, the median diagnostic interval was longer for patients who were illiterate and who were single, divorced, widowed, or separated when compared with patients who were literate and married with a living spouse, respectively. However, these differences were not statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eAmong health system-related factors, the diagnostic interval was significantly longer if the first healthcare provider gave symptomatic treatment and did not refer the patient (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (\u003cb\u003eSupplementary Table\u0026nbsp;2\u003c/b\u003e). The diagnostic interval was longer when cancer was first suspected after the patient had consulted at least two healthcare providers (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). However, the treatment interval was significantly longer for patients where cancer was suspected by either the first or second healthcare provider (p\u0026thinsp;=\u0026thinsp;0.020). The patient, diagnostic, and treatment intervals were longer for patients using public transport as compared to those renting vehicles, taxis, or using private vehicles. However, these differences were not statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The grade and stage of the disease were not significantly associated with patient, diagnostic and treatment intervals (\u003cb\u003eSupplementary Table\u0026nbsp;3\u003c/b\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Reasons for delay in diagnosis and treatment of oral cancer\u003c/h2\u003e \u003cdiv id=\"Sec19\" class=\"Section3\"\u003e \u003ch2\u003e3.4.1 Quantitative survey findings\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003ePatient interval\u003c/strong\u003e \u003cp\u003eA significant majority, 114 (98.2%), attributed their delay to considering their symptoms as minor and waiting for them to subside. Other reasons included being too busy to make time for a doctor (3.7%) and concerns about the costs of consulting a doctor or visiting a hospital (2.7%). Additional factors cited were the lack of an accompanying person to visit the hospital (0.9%) and worries about prescribed tests (0.9%). Other reasons, including fear of cancer and disbelief in allopathic treatments, were less common, with each noted by only one participant (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eReason for seeking delay in healthcare after identification of symptom (patient interval) (N\u0026thinsp;=\u0026thinsp;116)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReason*\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFound it difficult to get an appointment with a particular doctor.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (0.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eToo busy to make time to go to the doctor.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4 (3.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHad too many other things to worry about.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (0.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWorried about tests prescribed by doctors.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (0.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDid not have an accompanying person to visit the hospital.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (0.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAttributed symptoms as minor and waited for them symptoms to subside\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e114 (98.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDid not have money to consult a doctor/visit a hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3 (2.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDid not believe in Allopathic medicines and treatment and preferred alternative medicines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (0.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAfraid of cancer and delayed seeing the doctor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (0.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBelieved care is not curable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (1.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDid not share my symptoms with the family as they would get worried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (0.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003e*Not mutually exclusive\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eDiagnostic interval\u003c/strong\u003e \u003cp\u003eThe primary reason cited was that the initial healthcare provider did not suspect cancer, reported by 58 (50.0%) of participants. Financial constraints also played a role, with 18 (15.5%) unable to afford timely tests and another 18 (15.5%) delaying biopsy due to initial symptom relief from symptomatic treatment. Additional reasons included difficulty in reaching facilities with biopsy testing available (8.6%), long waiting times for tests (8.6%), and concerns about the biopsy procedure (4.3%). Notably, 23 (19.8%) of participants felt that their diagnosis was not delayed, highlighting varied perceptions of the diagnostic timeline (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eReason for delay in diagnosis after seeing a healthcare provider (diagnostic interval) (N\u0026thinsp;=\u0026thinsp;116)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReason\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe initial healthcare provider did not suspect cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e58 (50.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFound it difficult to reach the facility with biopsy testing available\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10 (8.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDid not have money to get the tests done on time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18 (15.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDid not have the time to get the tests done\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6 (5.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWas afraid of confirming the diagnosis of cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3 (2.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWas afraid of the biopsy procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5 (4.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe waiting time for tests to get done was long\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10 (8.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDelayed biopsy due to initial relief of symptoms with symptomatic treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18 (15.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDelayed biopsy hoping the symptoms would subside on their own\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (0.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDelayed biopsy to seek other opinions on the problem\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4 (3.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFalse negative biopsy on initial evaluation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11 (9.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCOVID lockdown delayed biopsy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (0.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSickness of another person in the family\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3 (2.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDid not feel that diagnosis was delayed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23 (19.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eTreatment interval\u003c/strong\u003e \u003cp\u003eA notable 48 (41.4%) of participants felt that their treatment was not delayed. Among those who experienced delays, the most common reasons included lengthy pre-treatment investigations after biopsy (19.8%) and difficulty in obtaining timely appointments for cancer treatment (14.6%). Financial barriers also affected treatment initiation, with 9 (7.8%) unable to afford cancer treatment. Other reasons included delays due to uncontrolled chronic diseases (6.9%) and opting for alternative forms of treatment (5.1%) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eReasons for delay in initiation of treatment following diagnosis of oral cancer (treatment interval) (N\u0026thinsp;=\u0026thinsp;116)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReason\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOpted for alternate forms of treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6 (5.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWas afraid of cancer treatment \u0026ndash; chemotherapy/surgery/radiation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4 (3.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFound it difficult to reach a center with cancer treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (0.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDid not have money for cancer treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9 (7.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDid not have time to start cancer treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (1.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnother acute illness delayed treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5 (4.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther uncontrolled chronic disease delayed cancer treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8 (6.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFound it difficult to get a timely appointment for cancer treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17 (14.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre-treatment investigations following biopsy took time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23 (19.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther personal reasons\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6 (5.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDid not feel that treatment was delayed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e48 (41.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section3\"\u003e \u003ch2\u003e3.4.2 Qualitative findings\u003c/h2\u003e \u003cp\u003eA total of 11 patients with oral cancer were interviewed following which saturation of themes was achieved. \u003cb\u003eSupplementary Table\u0026nbsp;4\u003c/b\u003e presents the sociodemographic and disease characteristics of study participants who underwent in-depth interviews. The mean (SD) age of the participants was 53.5 (10.5) years. The group consisted of 7 males and 4 females. Educational attainment varied, with 4 participants being illiterate, 4 having completed high school, and 2 holding graduate degrees. Out of the 11 participants, 9 participants were Hindu, while 2 were Muslim. The majority (8 participants) were at Stage IV. The grades of differentiation included poorly differentiated (2 participants), moderately differentiated (5 participants), and well-differentiated (4 participants). The median patient interval was 31.0 days, with an interquartile range (IQR) of 3.0 to 92.0 days. The diagnostic interval had a median of 176.0 days and an IQR of 80.0 to 304.0 days. For the treatment interval, the median was 46.0 days, accompanied by an IQR of 26.0 to 46.0 days. Lastly, the total interval showed a median of 233.0 days, with an IQR of 166.0 to 594.0 days.\u003c/p\u003e \u003cp\u003eThe themes identified for delay in seeking care, getting diagnosed, and starting treatment are listed in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThemes identified for patient, diagnostic, and treatment interval through qualitative interviews (N\u0026thinsp;=\u0026thinsp;11)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of interval\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTheme\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003ePatient interval\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePoor access to healthcare\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLack of awareness in the patient\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLack of support to go to the hospital\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInitial improvement of symptoms due to self-medication with over-the-counter medications\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther family events requiring urgent attention\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003e\u003cb\u003eDiagnostic and Treatment interval\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLack of awareness among healthcare providers and patients\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLack of time due to job\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFinancial constraints and lack of government facilities for treatment\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDelay in treatment due to non-availability of early appointment for investigations\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLack of patient navigation system at hospitals\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDelay due to poor access to treatment centers and overcrowded public health centers\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\u003cp\u003ePatient interval:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1.\u0026nbsp; \u0026nbsp;Poor access to healthcare: Participants expressed their struggles with accessing medical care, often due to geographical barriers. Lack of cancer treatment facilities in their hometown, lack of access to transport, and long travel time to the nearest health center affected early health seeking.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;There was no doctor in our village. We had to travel 2 hours to the city to show a doctor.\u0026quot; - P3\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e2.\u0026nbsp; \u0026nbsp;Lack of awareness in the patient: Patients commonly also reported that they would have sought early care had they known that the initial symptom was due to cancer. For some, misinformation and myths regarding the initial symptom also led to a delay in seeking care. Patients therefore sought care only when the symptoms worsened.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;I had tooth pain. Some people told me not to get the tooth extracted as it would lead to blindness.\u0026quot; - P2\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Initially I had only an ulcer and when the problem progressively increased, I went to a local informal provider.\u0026quot; - P10\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e3.\u0026nbsp; \u0026nbsp;Lack of support to go to the hospital: People living in rural areas and the elderly also found it difficult to access healthcare as there was nobody to accompany them to the hospital.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;I was in the village and my son was working in the city. There was no one living with me in the village who could take me to the hospital\u0026quot; - P4\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e4.\u0026nbsp; \u0026nbsp;Initial improvement of symptoms due to self-medication with over-the-counter medications: Due to poor access to trained healthcare professionals, for their initial symptoms of ulcer and pain, patients often bought over-the-counter medications. The initial relief in symptoms due to self-medication also contributed to a delay in health seeking from trained professionals.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;The pain resolved when I took painkillers and so I was not worried. I took painkillers for 3 months.\u0026quot; - P2\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e5.\u0026nbsp; \u0026nbsp;Other family events requiring urgent attention - A patient mentioned a delay in seeking care due to other events in the family that required urgent attention.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIn the words of P1: \u0026quot;A relative died in my family. I had to go there and so could not see the doctor as soon as the pain started.\u0026quot; \u0026emsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDiagnostic and treatment interval\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e1.\u0026nbsp; \u0026nbsp;\u003c/em\u003eLack of awareness among healthcare providers and patients: Patients reported that the initial healthcare provider, both formal and informal practitioners, they saw for their complaints did not suspect cancer. As the patients themselves were also not aware, they did not consider the symptoms to be significant. This delayed the diagnosis of the cancer. Due to a lack of awareness, the informal providers also contributed to the delay in diagnosis and treatment by delaying referral to trained healthcare providers.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAnother patient (P8) said, \u0026quot;The doctor I saw in the beginning gave an ointment following which I had partial relief in symptoms. The doctor did not tell me to go to a bigger hospital. I came here by myself when my condition worsened. If the doctor had told me that this was an ulcer and if does not improve after a few days then get checked in a bigger hospital then my treatment would have started early.\u0026quot;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;The doctor kept giving treatment and said that he would cure it. We showed another doctor and asked him if this was cancer. I had seen a person with cancer before so I had an intuition. But the doctor said it is not what I was thinking and that the ulcer will heal.\u0026quot; - P9\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOften symptomatic treatment given by the first healthcare provider led to an improvement in symptoms which also led to delay as the patient considered the symptoms to be benign.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;The first doctor I showed gave me some medications that improved my symptoms. However, the symptoms did not settle after 3 months. The doctor then advised a CT scan and referred to Delhi.\u0026quot; - P3\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOn the contrary, early suspicion from a doctor helped a patient seek care sooner.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;The first doctor we saw directly told us that this is cancer and we need to go to a bigger hospital to start treatment.\u0026quot; - P6\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e2. \u0026nbsp; Lack of time due to a job - A patient reported that as he could not take leave from his work, he kept getting symptomatic treatment from local informal providers and delayed seeking care from a trained practitioner.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the words of P11, \u003cem\u003e\u0026quot;I used to get paid on a daily basis and so showed local informal doctors as it took less time and I could avoid taking leave.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e3. \u0026nbsp; Financial constraints and lack of government facilities for treatment: Financial constraints also led to a delay in early diagnosis and initiation of treatment as the cost of diagnostic tests and treatment was unaffordable in the private hospitals and the same services were either inaccessible or not available in the public hospitals.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;The ENT doctor took Rs 400 fees and told me I did not have any problem. He advised tests for Rs 6000 and I did not get them done as they were too expensive.\u0026quot; - P2\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e4. \u0026nbsp; Lack of patient navigation system at hospitals: Patients reported that the treatment was delayed as the tests couldn\u0026rsquo;t be done on time. The reason for the delay in tests was that the patient and caregivers did not know where the tests had to be done in the hospital.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;The investigations took time as it was not clearly conveyed which forms and whose signatures were needed for the tests to be done under the Delhi government\u0026apos;s scheme. If all the information was conveyed together the tests would have taken less time and treatment would have started early.\u0026quot; - P4\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e5.\u0026nbsp; \u0026nbsp;Delay in treatment due to non-availability of early appointments for investigations - Patients reported that after getting the diagnosis confirmed through biopsy, treatment was delayed because of the tests that had to be done before starting treatment. Various blood investigations and imaging tests took time because of which treatment could not be started as soon as the patient was diagnosed with cancer. In the words of P2 -\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;There was a delay in starting treatment as investigations took too much time. We were asked to get a CT scan done but the earliest appointment was after 5 months in the hospital.\u0026quot;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e6. \u0026nbsp; Delay due to poor access to treatment centers and overcrowded public health centers: Even after getting diagnosed early and getting all tests done, patients reported delays in the initiation of treatment due to the non-availability of early treatment appointments in government hospitals. Poor referral mechanisms within government hospitals also contributed to delays. This has been corroborated by the following response from the participant:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;The treatment started in X hospital but they did not have radiation therapy. They referred me here but this hospital refused to give radiation therapy as chemotherapy was given in a different hospital. I had to do multiple rounds of both hospitals and after 2 to 3 months radiation therapy started.\u0026quot; - P7\u003c/em\u003e\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThe study examined various intervals in patient care for oral cancer, revealing significant delays in diagnosis and treatment. The diagnostic interval (median\u0026thinsp;=\u0026thinsp;88.0 days) was found to be the longest followed by the treatment (median\u0026thinsp;=\u0026thinsp;54.5 days) and patient intervals (median\u0026thinsp;=\u0026thinsp;13.5 days). Overall, the total interval, combining all phases, had a median of 194.5 days. A cancer treatment center in Maharashtra classified delays in care into primary, secondary, and tertiary delays. The primary delay, from symptom onset to visiting a primary care physician, was the longest at 2.75 months. Secondary delay, from seeking advice to referral to a tertiary center, was 1.94 months, while tertiary delay, from referral to the start of treatment, was 1.4 months (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). A study by Swaminathan et al. (2024) examined diagnostic delays and the impact of various patient and tumor factors on these delays. The study interviewed 120 patients and found that the median primary delay was 90 days, while the median secondary delay was 11 days (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). While the diagnostic interval was comparable to existing literature from India, the patient interval was significantly shorter in our study population. This could be due to easy access to informal healthcare providers and pharmacies, both of which were also considered to be a part of the healthcare system in this study to assess the delay caused due to them.\u003c/p\u003e \u003cp\u003eThe first healthcare provider suspected cancer in 43.1% of cases, with dental specialists being the most common initial contact (31.0%). This was in contrast to the study by Rath et al (2018) where only 7% of the patients first met a dentist (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Upon seeking care, patients visited an average of two healthcare providers before receiving a diagnosis. Initial advice varied, with 55.2% of providers dismissing the symptoms as minor, 22.4% recommending a biopsy, and another 22.4% referring the patient to a higher center. Most patients (98.2%) attributed delays to considering their symptoms minor and waiting for them to resolve. Other reasons for delay included being too busy (3.7%) or concerns about the costs of care (2.7%). The qualitative findings from the in-depth interviews revealed several key factors contributing to delays in seeking care and receiving timely diagnosis and treatment for cancer. Poor access to healthcare, especially in rural areas, was a major barrier to timely care. Patients often traveled long distances to medical centers, while others delayed seeking help due to a lack of awareness or attributed their symptoms to less serious causes. Elderly patients and those living alone struggled to access care without family support, and self-medication delayed proper treatment. Similar reasons for delay were reported by Rath et al (2018), for example, lack of awareness, hope that the lesion will heal spontaneously, lack of perception of seriousness, and financial constraints (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAfter consulting healthcare providers, 50.0% of patients reported delays in diagnosis because the initial provider did not suspect cancer, while financial barriers (15.5%) and delays in biopsy procedures (15.5%) were also common factors. The in-depth interviews revealed that diagnostic delays were linked to a lack of awareness among both patients and healthcare providers. Many initial consultations did not recognize cancer symptoms, leading to prolonged treatment for less serious conditions. Financial constraints, including the high cost of tests and treatment, further delayed care, especially in areas lacking affordable government services. In 2014, Akram et al, in Uttar Pradesh, reported significant risk factors contributing to delays in seeking hospital care included older age, low socioeconomic status, rural residence, lack of awareness about head and neck cancer, downplaying of symptoms as minor, absence of fear, and reliance on alternative therapies (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOnce diagnosed, 41.4% of participants felt their treatment was not delayed, but among those who experienced delays, the most common reasons included lengthy pre-treatment investigations (19.8%), difficulty scheduling cancer treatment appointments (14.6%), and financial constraints (7.8%). Other delays were linked to chronic health conditions (6.9%) or opting for alternative treatments (5.1%). In-depth interviews revealed that the system-level issues, such as long waiting times for tests and a lack of coordinated referrals, added further delays once patients sought care. These logistical and financial barriers contributed to prolonged intervals between diagnosis and treatment, potentially affecting patient outcomes.\u003c/p\u003e \u003cp\u003eThe analysis of factors associated with the patient interval identified a few trends, although they did not reach statistical significance. For example, the type of transportation to healthcare facilities showed a tendency where those using public transport had a longer patient interval (15.0 days) compared to those using private or rented transport (8.0 days, p\u0026thinsp;=\u0026thinsp;0.486). This trend could reflect differences in the accessibility and speed of care, though further research would be necessary to confirm their significance. Despite these trends, most other factors, including demographic characteristics (age, gender, education), did not show meaningful associations with patient intervals.\u003c/p\u003e \u003cp\u003eIn a 2024 study by Swaminathan et al, education was reported to play a significant role in literate patients presenting earlier for treatment (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). However, a similar finding was not seen in this study. In a study by Bayable et al (2023) in Ethiopia variables such as being female, rural residence, low social support, not having any other comorbidity and poor awareness were associated with delayed health seeking (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Similar to this study, a study by Bhatia et al (2018) in Botswana reported that patients living with larger families were less likely to experience a help-seeking delay for cancer (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFamily structure was found to significantly influence the diagnostic delay, with patients from nuclear families experiencing a longer median diagnostic interval (101.0 days) compared to those from joint families (49.5 days) (p\u0026thinsp;=\u0026thinsp;0.013). Additionally, patients who received symptomatic treatment without referral had a significantly longer median diagnostic interval of 119.5 days, compared to those referred to a higher center, whose median interval was 47.5 days (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Gender showed a trend toward significance, with females reporting longer diagnostic intervals (198.0 days vs. 86.0 days for males) (p\u0026thinsp;=\u0026thinsp;0.067). Other sociodemographic factors, including age, education, marital status, and socioeconomic status, did not show significant associations with diagnostic intervals. These findings suggest that family structure and the referral process are important determinants of diagnostic intervals, while other factors, such as gender, require further exploration.\u003c/p\u003e \u003cp\u003eIn a study by Poum et al (2014), significant associations were reported between delay in breast cancer diagnosis and education, family income, time to referral, and number of consultations with a surgeon before diagnosis (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). The findings of a systematic review in 2021 by Lima et al suggested that a lack of awareness about the signs and symptoms of oral cancer, along with the undervaluation of self-care, are strongly linked to delays in its diagnosis (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOlder patients (60 years and above) had a median treatment interval of 35.5 days, slightly shorter than the 56.5 days for those under 60, but this difference was not statistically significant (p\u0026thinsp;=\u0026thinsp;0.180). Similarly, while males had a median treatment interval of 55.5 days and females had 46.0 days, the difference was also not significant (p\u0026thinsp;=\u0026thinsp;0.796). Literature on factors associated with treatment delay in patients with oral cancer is lacking from India, however, a study by Saka-Herran et al in 2021 reported that patients with advanced-stage disease, primary treatment with radiotherapy, treatment at an academic facility, and transitions in care were associated with prolonged pre-treatment intervals (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cb\u003ePolicy recommendations\u003c/b\u003e \u003c/p\u003e \u003cp\u003eTo reduce time taken for diagnosis and treatment of oral cancer, interventions are necessary to reduce all three intervals, i.e., patient, diagnostic and treatment. Increasing awareness of the general population regarding harmful effects of tobacco, increasing coverage population-based screening, improving access to primary health care and promoting health seeking behaviour will help in reducing patient interval. Increasing awareness regarding presentation of oral cancer in healthcare providers, improving access to and availability of diagnostic services with the use of digital health or hub and spoke model of healthcare, covering expense of diagnostic services in government funded insurance schemes and addressing cancer related stigma in the community will help in reducing the diagnostic interval in oral cancer management. Lastly, improving access to cancer treatment by establishing government funded cancer treatment centers, especially in rural parts of the country and providing insurance coverage and access to social security schemes to protect the family from financial toxicity of the disease will help in reducing the treatment interval in oral cancer management.\u003c/p\u003e \u003cp\u003e \u003cb\u003eStrengths and limitations\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis is the first study to assess all three levels of intervals - patient, diagnostic, and treatment - in patients with oral cancer in India. This study was conducted in a referral public health center for cancer treatment which sees footfall of people from the middle and lower socioeconomic populations in India in which oral cancer is commonly seen. Therefore, the findings represent the struggles faced by a majority of the people who are diagnosed with oral cancer. Being a mixed methods study, the qualitative part of the study helped in identifying reasons for delays that were missed in the quantitative survey. However, despite these strengths, the study has a few limitations. First, since the date of symptom identification was based on memory recall there is a possibility of a recall bias. However, a pseudo-exact date method was used to identify the most accurate date of symptom identification which might not be exact. Second, due to a relatively small sample size, the number of women included in the study was small, and therefore the gender disparity in seeking treatment could not be extensively studied. However, the reported trend highlighted that woman took longer to be diagnosed than men. This trend requires further investigation. Third, the pathways to treatment were based on patient recall and could not be verified using medical records in most patients. Fourth, the study included only participants from public health centers, and patients from private health centers could not be enrolled. Therefore, the findings cannot be generalized to private-sector hospitals. Lastly, being a cross-sectional study, the association of delay on the overall survival of patients could not be studied in this study.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eA majority of the patients with oral cancer presented in advanced stage disease with preventable delays at various levels. The diagnostic interval was found to be the longest followed by treatment and patient interval. There are various risk factors predisposing people to these delays. There is a need to increase awareness regarding the harmful effects of tobacco along with an improvement in access to tobacco cessation services. There is also a need for screening in high risk population for oral cancer along with improvement in awareness regarding early symptoms of oral cancer both in healthcare providers and patients. Future studies should study the impact of these delays on the survival of the patients and assess interventions that reduce these delays.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eConflict of interest: None\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Ethics clearance was taken from the Institutional Ethical Committee (F.1/IEC/MAMC/MD/MS(96/02/2023/No.125) on 15.05.2023.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data will be available on reasonable request to the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study did not receive any funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePS \u0026ndash; Conceptualization, Data Collection, Data Analysis, Data interpretation, Manuscript \u0026ndash; Original Draft wiritng\u003c/p\u003e\n\u003cp\u003eMMS \u0026ndash; Conceptualization, Data interpretation, Manuscript \u0026ndash; Review and Editing, Supervision\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eALB - \u0026nbsp;Conceptualization, Data interpretation, Manuscript \u0026ndash; Review and Editing\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAS - Conceptualization, Data interpretation, Manuscript \u0026ndash; Review and Editing\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRM - Conceptualization, Data interpretation, Manuscript \u0026ndash; Review and Editing\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author (PS) would like to thank Dr Nandini Sharma, ex-Dead, Maulana Azad Medical College for her constant support and guidance. \u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGlobal burden of 369 diseases and injuries in 204 countries and territories, 1990\u0026ndash;2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet Lond Engl. 2020 Oct 17;396(10258):1204\u0026ndash;22. \u003c/li\u003e\n\u003cli\u003eSung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin. 2021;71(3):209\u0026ndash;49. \u003c/li\u003e\n\u003cli\u003eSathishkumar K, Chaturvedi M, Das P, Stephen S, Mathur P. Cancer incidence estimates for 2022 \u0026amp; projection for 2025: Result from National Cancer Registry Programme, India. Indian J Med Res. 2022;156(4 \u0026amp; 5):598\u0026ndash;607. \u003c/li\u003e\n\u003cli\u003eFerlay J, Colombet M, Soerjomataram I, Parkin DM, Pi\u0026ntilde;eros M, Znaor A, et al. Cancer statistics for the year 2020: An overview. Int J Cancer. 2021;149(4):778\u0026ndash;89. \u003c/li\u003e\n\u003cli\u003eIrani S. New Insights into Oral Cancer\u0026mdash;Risk Factors and Prevention: A Review of Literature. Int J Prev Med. 2020 Dec 30;11:202. \u003c/li\u003e\n\u003cli\u003eBray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018 Nov;68(6):394\u0026ndash;424. \u003c/li\u003e\n\u003cli\u003eBorse V, Konwar AN, Buragohain P. Oral cancer diagnosis and perspectives in India. Sens Int. 2020;1:100046. \u003c/li\u003e\n\u003cli\u003eFactsheet - National Cancer Registry Programme (ICMR-NCDIR) [Internet] Bengaluru, India [cited 2024 Nov 23] Available from : https://ncdirindia.org/All_Reports/Report_2020/Factsheet/Fact_Sheet_2020.pdf\u003c/li\u003e\n\u003cli\u003eSciubba JJ. Oral cancer. The importance of early diagnosis and treatment. Am J Clin Dermatol. 2001;2(4):239\u0026ndash;51. \u003c/li\u003e\n\u003cli\u003eScott SE, Walter FM, Webster A, Sutton S, Emery J. The Model of Pathways to Treatment: Conceptualization and integration with existing theory. Br J Health Psychol. 2013;18(1):45\u0026ndash;65. \u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Guide to cancer early diagnosis [Internet]. Geneva: World Health Organization; 2017 [cited 2023 Jan 2]. 48 p. Available from: https://apps.who.int/iris/handle/10665/254500\u003c/li\u003e\n\u003cli\u003eWeller D, Vedsted P, Rubin G, Walter FM, Emery J, Scott S, et al. The Aarhus statement: improving design and reporting of studies on early cancer diagnosis. Br J Cancer. 2012 Mar;106(7):1262\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003ePhilip PM, Kannan S. Patient Interval and Associated Factors in the Diagnostic Journey of Oral Cancer: A Hospital-Based Cross-Sectional Study from Kerala, India. Asian Pac J Cancer Prev APJCP. 2021 Oct;22(10):3143\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003ePhilip PM, Kannan S. Tool development and validation of the oral cancer patient and diagnostic interval measure. Int J Community Med Public Health. 2022 Jan 28;9(2):819\u0026ndash;25. \u003c/li\u003e\n\u003cli\u003eOlesen F, Hansen RP, Vedsted P. Delay in diagnosis: the experience in Denmark. Br J Cancer. 2009 Dec 3;101 Suppl 2(Suppl 2):S5-8. \u003c/li\u003e\n\u003cli\u003ePlanning Department, Government of National Capital Territory of Delhi. Poverty line in Delhi 2023-24 [Internet]. Delhi, India [cited 2024 Nov 23]. Available from: https://delhiplanning.delhi.gov.in/sites/default/files/Planning/20._poverty_line.pdf\u003c/li\u003e\n\u003cli\u003eJavalkar SR, H S, Davalagi SB, S VG. Socio economic status assessment in India: history and updates for 2024. Int J Community Med Public Health. 2024 Feb 29;11(3):1369\u0026ndash;77. \u003c/li\u003e\n\u003cli\u003eJoshi P, Nair S, Chaturvedi P, Nair D, Agarwal JP, D\u0026prime;Cruz AK. Delay in seeking specialized care for oral cancers: Experience from a tertiary cancer center. Indian J Cancer. 2014 Jun;51(2):95. \u003c/li\u003e\n\u003cli\u003eSwaminathan D, George NA, Thomas S, Iype EM. Factors associated with delay in diagnosis of oral cancers. Cancer Treat Res Commun. 2024;40:100831. \u003c/li\u003e\n\u003cli\u003eRath H, Shah S, Sharma G, Mishra E. Exploring determinants of care-seeking behaviour of oral cancer patients in India: A qualitative content analysis. Cancer Epidemiol. 2018 Apr 1;53:141\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eAkram M, Siddiqui SA, Karimi AM. Patient Related Factors Associated with Delayed Reporting in Oral Cavity and Oropharyngeal Cancer. Int J Prev Med. 2014 Jul;5(7):915\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eBayable A, Tegenaw A, Tesfaye Z, Lidetu T, Assefa A, Dessie G. Delay in health-seeking behaviour and associated factors among adult patients with cancer in Ethiopia: a multicentre cross-sectional study. BMJ Open. 2023 Aug 29;13(8):e071406. \u003c/li\u003e\n\u003cli\u003eBhatia RK, Rayne S, Rate W, Bakwenabatsile L, Monare B, Anakwenze C, et al. Patient Factors Associated With Delays in Obtaining Cancer Care in Botswana. J Glob Oncol. 2018 Aug;4:1\u0026ndash;13. \u003c/li\u003e\n\u003cli\u003ePoum A, Promthet S, Duffy SW, Parkin DM. Factors associated with delayed diagnosis of breast cancer in northeast Thailand. J Epidemiol. 2014;24(2):102\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eLima AM da C, Meira IA, Soares MSM, Bonan PRF, M\u0026eacute;lo CB, Piagge CSLD. Delay in diagnosis of oral cancer: a systematic review. Med Oral Patol Oral Cir Bucal. 2021 Nov;26(6):e815\u0026ndash;24. \u003c/li\u003e\n\u003cli\u003eVarela-Centelles P, Seoane J, Lopez-Cedrun J l., Fernandez-Sanroman J, Garc\u0026iacute;a-Martin J m., Takkouche B, et al. The length of patient and primary care time interval in the pathways to treatment in symptomatic oral cancer. A quantitative systematic review. Clin Otolaryngol. 2018;43(1):164\u0026ndash;71. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6318005/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6318005/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e: The burden of oral cancer is rising, especially in the Indian subcontinent, which contributes one-third of all global cases. Oral cancer, though preventable, often goes undetected until later stages. There is a paucity of literature on the duration of patient, diagnostic, and treatment intervals for oral cancer management in India. The study aimed to estimate the patient, diagnostic, and treatment intervals for oral cancer patients and to explore factors contributing to delays.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThis cross-sectional mixed-method study was conducted at Lok Nayak Hospital in Delhi. The study included 116 patients with histopathologically confirmed oral cancer in the quantitative survey and 11 in the qualitative in-depth interviews who were receiving treatment within the last three months. Purposive sampling was used for both the quantitative survey and qualitative interviews. Statistical analysis was performed using SPSS, while qualitative data were manually coded to identify themes. The ‘Aarhus statement’ guidelines were followed in designing and reporting the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe study population had a mean age of 48 years, with a majority being male (87.9%), and Hindu (66.4%), half were from lower socioeconomic groups (50%) and 65.5% presented with Stage IV disease. The median patient interval was 13.5 (5.0, 59.5) days, the diagnostic interval was 88.0 (39.0, 218.2) days, and the treatment interval was 54.5 (28.8, 92.5) days, with a total median interval of 194.5 (133.5, 427.5) days. Delays were mainly due to symptoms being dismissed as minor (98.2%), initial healthcare worker not suspecting cancer (50.0%) and pre-treatment investigation delays (19.8%). Key qualitative barriers included poor healthcare access (especially in rural areas), lack of awareness of symptom severity, reliance on self-medication, and family-related distractions. Delayed recognition by initial healthcare providers contributed to further delays. Family structure and advice by the first heart care provider significantly influenced diagnostic interval.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eA majority of the patients with oral cancer presented with advanced-stage disease with diagnostic interval being the longest followed by treatment and patient intervals. Future studies should study interventions to reduce these delays and also assess the impact of these delays on the disease outcome.\u003c/p\u003e","manuscriptTitle":"Delay in diagnosis and treatment of patients with oral cancer seeking treatment in a public tertiary hospital in India","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-01 06:46:28","doi":"10.21203/rs.3.rs-6318005/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ad616b80-c0ca-4342-899e-4de17568959d","owner":[],"postedDate":"April 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-04-01T06:46:30+00:00","versionOfRecord":[],"versionCreatedAt":"2025-04-01 06:46:28","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6318005","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6318005","identity":"rs-6318005","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}