|Year : 2016 | Volume
| Issue : 2 | Page : 63-70
A cross-sectional study on different time intervals from the appreciation of symptoms to final diagnosis in inoperable primary lung cancer: An Eastern Indian experience
Surajit Chatterjee1, Swapnendu Misra2, Ira Das3, Ritam Chakraborty1, Kaushik Saha4, Somenath Kundu1, Pulak Kumar Jana5
1 Department of Respiratory Medicine, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India
2 Department of Respiratory Medicine, North Bengal Medical College and Hospital, Susrutanagar, Darjeeling, West Bengal, India
3 Department of Pediatric Medicine, Chittaranjan Seva Sadan and Sishu Sadan Hospital, Kolkata, West Bengal, India
4 Department of Respiratory Medicine, Burdwan Medical College, Burdwan, West Bengal, India
5 Department of Respiratory Medicine, Bankura Sammilani Medical College, Bankura, West Bengal, India
|Date of Web Publication||10-Jun-2016|
38, Raj Krishno Ghoshal Road, Kolkata - 700 042, West Bengal
Source of Support: None, Conflict of Interest: None
Background: Lung cancer is the most commonly diagnosed and most common cause of death from cancer worldwide. Diagnostic delays continue to remain a common problem, and surgery could be offered in time in <5% of the cases. Aims and Objectives: Assessment of different time intervals from the appreciation of symptoms to final diagnosis and identify probable factors contributing to delay in those intervals. This study will be helpful to find out the obstacle in the lung cancer diagnosis. Settings and Design: Observational cross-sectional tertiary care hospital-based study. Materials and Methods: Fifty cases were collected consecutively according to inclusion and exclusion criteria and assessed based on prefixed questionnaires. Application interval, referral interval, tertiary center interval, and total time to diagnose were measured. Results: Among 50 cases, 36 cases (72%) were male and 14 cases (28%) were female. Mean age was 55.50 years (range 22–81; standard deviation [SD] 12.68). Squamous cell carcinoma was found more in male and adenocarcinoma in female group (Fisher's P 0.0250). Mean application interval mean was 92 days (range 23–210, SD 41.81), mean referral interval 39 days (range 2–160, SD 26.89), mean interval at tertiary center 15 days (range 5–40, SD 8.027), and total interval mean was 146 days (range 45–240, SD 47.33). Among total cases, application delay was in 38 (76%) cases and referral delay in 35 (70%) cases. Median application interval in delay group was 94 days, and in no delay group was 40 days. Among total cases, 35 (70%) were in referral delay group. There was mean referral interval of 50 days and 14 days, respectively among the referral delay and no delay groups. Conclusion: There was maximum delay in application interval. Awareness of lung cancer and level of education along with neglect of a cough as index symptom are the major factors causing application delay. Significant numbers of the patient were not advised computed tomography thorax at the appropriate time and instead received empirical anti-tubercular treatment causing referral delay.
Keywords: Delay, diagnosis, lung cancer
|How to cite this article:|
Chatterjee S, Misra S, Das I, Chakraborty R, Saha K, Kundu S, Jana PK. A cross-sectional study on different time intervals from the appreciation of symptoms to final diagnosis in inoperable primary lung cancer: An Eastern Indian experience. J Assoc Chest Physicians 2016;4:63-70
|How to cite this URL:|
Chatterjee S, Misra S, Das I, Chakraborty R, Saha K, Kundu S, Jana PK. A cross-sectional study on different time intervals from the appreciation of symptoms to final diagnosis in inoperable primary lung cancer: An Eastern Indian experience. J Assoc Chest Physicians [serial online] 2016 [cited 2021 Dec 7];4:63-70. Available from: https://www.jacpjournal.org/text.asp?2016/4/2/63/183837
| Introduction|| |
Lung cancer is the most commonly diagnosed cancer in the world (1.8 million, 13.0% of the total) and most common cause of death from cancer worldwide. About 55% of total diagnosed cases are from the developing countries. In India, 53,728 male and 16,547 female patients were diagnosed with lung cancer in the year 2012, and approximately 48,679 males and 15,062 females died due to the disease (GLOBOCAN 2012).
Several risk factors such as age beyond 40 years, male sex, smoking, occupational-environmental exposure, genetic predisposition, family history of cancer, and co-morbidities such as -chronic obstructive pulmonary disease (COPD), lung fibrosis, other cancers, HIV infection are associated with the development of lung cancer.
It has been accepted that survival rates in lung cancer depend on early diagnosis and treatment, especially much more significant in a high-risk population. The term “delay” in the cancer literature is used both to refer to time delays and to denote advanced stage at presentation. It is easy to presume that delays result in a reduction of survival time. Diagnostic and treatment delays continue to remain a very common problem among patients with lung cancer. Reducing delays may increase the proportion of early stage cancers and improve survival.
This study focuses on the factors contributing to delay in the diagnosis of lung cancer with special reference to high-risk population. The patient-related delay may be due to delay in visiting nearest healthcare facility due to several demographic and socio-educational factors. Physician-related factors may be due to initial misdiagnosis, inadequate investigations and follow-up, delayed referral, delay in a referral center in making diagnosis and staging.
The aim of this study is to summarize the contributing factors in delaying diagnosis of lung cancer for our better knowledge. The idea to identify the factors contributing to the delay in the diagnosis of lung cancer will be helpful in the formulation of cancer screening plan and identification of obstacles in early diagnosis of lung cancer.
Aims and objectives
- Assessment of different time intervals from the appreciation of the first symptom by the patient to final diagnosis by the physician
- Identification of factors from both patients and physicians angle influencing delay in lung cancer
- Comparison of different time intervals in high-risk group with the low-risk population.
| Materials and Methods|| |
This study is an observational cross-sectional hospital-based study was conducted among consecutively selected 50 patients attending indoor and outdoor of Department of Pulmonary Medicine, Institute of Post Graduate Medical Education and Research and Seth Sukhlal Karnani Memorial Hospital, Kolkata, between April 2013 and March 2014.
Diagnosed lung cancer patients with available past medical records from 1st doctor visit to 1st visit in our department.
- Patient's of lung cancer considered for surgical resection
- Malignancy in any other parts of the body with lung metastasis
- Patient without relevant medical records
- Lack of informed consent.
Methods of data collection
- Preformed structured questionnaire
- Records of relevant medical prescriptions
- Records of previous and recent investigations.
Laboratory investigations, parameters and procedure
History and clinical examination include identification of risk factors such as smoking, COPD, post-tuberculosis (TB) fibrosis, past history of cancer, family history of lung cancer, index symptom, symptoms on presentation, detailed treatment history, general survey, respiratory system, and other systems examination.
Initial laboratory investigation includes blood R/E, liver function test, renal function test, chest X-ray, sputum for acid-fast Bacilli (AFB), etc.
Investigations to confirm malignancy
Pleural fluid study for malignant cell (M cell) by pap stain and cell block technique for as much as 3 times, fine-needle aspiration cytology (FNAC) and/or biopsy of palpable neck nodes ± immune-histochemistry (IHC), pleural biopsy ± IHC, ultrasonography (USG) thorax for assessment of lung mass and USG guided FNAC/tru-cut biopsy, contrast enhanced computed tomography (CECT) thorax and guided FNAC/tru-cut if mass lesion. Fiberoptic bronchoscopy and bronchoscopic biopsy for histopathological examination, lavage fluid for M cell, brush cytology, transbronchial needle aspiration (TBNA), etc.
Investigations for metastatic evaluation
USG whole abdomen with special reference to the liver and adrenal metastasis, CECT abdomen, and computed tomography ( CT) guided biopsy for confirmation of metastasis, CT brain and/or magnetic resonance imaging brain, etc.
Tumor-node-metastasis staging (AJCC 7th edition) Eastern Cooperative Oncology Group (ECOG) score.
Assessment of delay from prefixed questionnaire, records of available medical prescriptions and investigations-defining delays
Application interval and delay
Application interval is the interval between index symptom and first doctor visit. It mostly depends on sociodemographic factors.
For assessment of application interval delay, guidelines are not standardized. In our study, cut-off interval in application delay was chosen 60 days based on the Turkish study  and Indian Chandigarh based study by Jindal and Behera.
Referral interval and delay
Referral interval is the interval between the first visit to doctor and the first visit to the tertiary center. It mostly depends on an assessment of primary care physicians.
If referral interval exceeds 3 weeks, it is termed as referral delay. As there is a little role of sociodemographic factors in this interval, the delay was chosen based on the
“2 weeks wait” scheme used in U.K. for referral of patients with cancer to secondary care.
Tertiary center diagnostic interval and delay
If the interval between the first visit to tertiary center to final diagnosis is beyond 2 weeks, it was termed as tertiary center delay.
Assessment of possible factors responsible for different delays
Probable factors responsible for application delay
Age, sex, occupation, residence, education, knowledge awareness, index symptom, and symptom imposed doctor visit.
Probable factors responsible for referral delay
Initial diagnosis, initial treatment, initial chest X-ray done/not done, number of initial follow-up, CT thorax advised or not.
Probable factors responsible for tertiary center diagnostic delay
Number of diagnostic modalities used.
Statistical analysis plan
Data were collected and arranged on excel sheet for analysis. For statistical analysis, Statistica version 6
(Tulsa, Oklahoma, USA: Stat Soft Inc., 2001) was used. For numerical variables, there were normally distributed data and skewed data. For comparison between normally distributed data, Student's unpaired t-test was used. For skewed data, Mann–Whitney's U-test was applied. For comparison between categorical variables, Fisher's exact test and Chi-square test was applied. P value was calculated from the mentioned test and significance was drawn accordingly.
| Results and Analysis|| |
A total of 50 cases were included in this study, of them 36 cases (72%) were male, and 14 cases (28%) were female. Mean age of the study population was 55.50. For simplification, illiterate and primary school educated group were termed together as minimally educated group and the rest as an educated group. Among male and female minimally educated (illiterate or primary school education) are 21 (58.34%) and 8 (57.13%), respectively. About 90% of males are smoker, and 21% of females are smoker. COPD was most common co-morbidity (42%) followed by diabetes mellitus (4%) and post tubercular fibrosis (4%). In both male and female group, most cases were from rural areas.
Thirty-six cases were in the previously defined high-risk group, and 14 cases were in low- risk group. (Fisher's exact test P < 0.0001) [Table 1].
Overall squamous cell carcinoma was found in 52% of total cases and among 61% males. Adenocarcinoma was the most common malignancy in the female group.
Squamous cell carcinoma (66.67%) was predominant in the high-risk group (P < 0.0001 and 0.003, respectively) while adenocarcinoma featured more (85.71%) in low-risk groups.
Result analysis of application interval
Application interval delay was seen in 38 (76%) cases with a median interval of 94 days. Application interval variable was skewed. Among high-risk cases, such delay was seen in 29 (80.56%) cases. However, no significant differences in application interval were seen between high- and low- risk groups (Mann–Whitney U-test P 0.787).
Among 38 application delay cases, 29 cases (76.32%) were male and 9 (23.68%) were female. 28 cases (73.68%) were smoker, 26 (65.79%) were minimally educated, 16 (42.11%) patients had knowledge and awareness about lung cancer, 25 cases (65.79%) were from rural areas, 55.26% of cases had comorbid illness.
Index symptom was a statistically significant factor [Table 2]. A cough was most common symptom in delay group, whereas in no delay group, chest pain was a common symptom. (Chi-square test P = 0.0221).
No statistically significant relation was found between delay and variables such as - age, gender, residence, smoking status, co-morbidity, and doctor visit symptom.
Result and analysis of referral interval
In analysis of referral interval, there were delay in 35 (70%) cases with mean referral interval of 50.54 days. Referral interval was normally distributed data.
No statistically significant difference noted between high- and low-risk groups (Student's unpaired t-test P = 0.773).
Among the high-risk group, there was referral delay in 26 cases (72.22%).
Initial diagnosis varied among referral delay groups [Table 3].
Among referral delay cases, CT thorax was not done in 26 cases (74.28%) and among no referral delay cases; CT thorax was not done in 6 cases (40.00%). (Fisher's exact test P = 0.0281).
Among the referral delay group, 28 cases (80.00%) had done more than one follow-up and among no referral delay group 11 cases (73.33%) had done more than one follow-up.
Result analysis of interval at tertiary center
In analysis of interval at tertiary center (interval between a 1st visit to the tertiary center and final diagnosis), there were delay (interval >2 weeks) in 20 (40%) cases with mean interval at the tertiary center of 23.13 days
(range 15–40; standard deviation [SD] 6.360). Mean intervals were comparable between two groups.
Among the high-risk group, there were delay at the tertiary center in 15 cases (41.67%). Different diagnostic modalities were used to diagnose lung cancer [Table 4]. Whereas more than one diagnostic modality was used in all
|Table 4: Different diagnostic modalities used among tertiary centre delay groups|
Click here to view
20 delay cases (100.00%), only one diagnostic modality was used in 26 cases (86.67%) among total 30 no delay cases.
(Fisher's exact test P < 0.0001).
Of these 20 tertiary center delay cases, 10 cases (50.00%) were adenocarcinoma; 9 cases (45.00%) were squamous cell carcinoma and 1 case (05.00%) was small cell carcinoma. Of these 30 no tertiary center delay cases, 11 cases (36.67%) were adenocarcinoma; 17 cases (56.67%) were squamous cell carcinoma, and 2 cases (06.66%) were small cell carcinoma.
In the assessment of total time required to diagnose, no significant difference was found between high- and low-risk groups (Student's unpaired t-test P = 0.976).
Among total cases, 76% had delay in application interval; 70% had delay in referral interval, and 40% had delay in the interval at tertiary center. (Chi-square test P = 0.0004) [Table 5].
Among high-risk group, application delay was in 29 cases (80.56%); referral delay was in 26 cases (72.22%), and delay at tertiary center was in 15 cases (41.67%). (Chi-square test P = 0.0013) Student's unpaired t-test P = 0.000.
Application delay had a significant impact on the total time to diagnosis.
| Discussion|| |
Lung cancer is the most commonly diagnosed cancer and most common cause of mortality from cancer worldwide. The majority of lung cancers (>80%) are diagnosed at an advanced stage, i.e. Stage IIIB and IV, by when they are beyond the scope of curative resection. In our study (n = 50), 36 cases (72%) were male and 14 cases (28%) were female (male: female = 2.57:1), which corroborates with the fact that the overall age-adjusted lung cancer incidence is still higher in men than women [Figure 1]. Among 50 cases, mean age in years was 55.50 ± SD 12.68 with a range of 21–81. About smoking status, our study was comparable with other Indian studies, all of which showed significant male predominance. The most common co-morbidity associated with lung cancer in our study was COPD, which was attributable to smoking. Among the total cases, about 72% cases were in high-risk group which corroborates with the fact that risk factors such as – smoking status, inherited predisposition, elderly age group, nonmalignant pulmonary disease like COPD and pulmonary fibrosis, infections like HIV and environmental exposure to carcinogen are associated with increased incidence of lung cancer shown in several studies in past. Among high-risk group, the percentage of the female population is 11.12% compared to 88.88% male population which majorly corresponds to the study by Noronha et al. at Tata Memorial Hospital possibly because of the fact that larger proportion of females were nonsmokers as compared to males who were smokers.
Functional assessment was done by ECOG score in our study, and median score was 2 ± SD 1.072 (interquartile range [IQR] 1.75–3). Performance status correlates well with the number and severity of symptoms.
In our study, most common variety of nonsmall cell carcinoma was squamous cell carcinoma, which was similar to observation by Behera et al. in their study in 2012. Study of Noronha et al., at Tata Memorial Hospital, Mumbai found that adenocarcinoma accounts for 44% of NSCLC while only 26% are squamous-cell carcinoma. Results from our study do not suggest that a pathologic shift may have occurred in India; although, the large sample size is required to comment about it.
Previous studies indicated that there were several delays between the onset of symptoms and final diagnosis in lung cancer patients. The delays can be described as total delay, application (patient's) delay, referral delay, delay at tertiary/referral center.
In our study, application interval median was 90 days ± SD 41.81 (IQR 63.75–120). In India, there is no specific guideline about the application time. According to an Indian study 32.6% lung cancer patients presented within 3 months, 46.4% of patients presented within 3–6 months, and 21% presented beyond 6 months of development of symptoms. Median application interval among the delay group was 94 days ± SD 33.869 (mean 108.29 days. IQR 86–120) which is less than the application delay of 143 days in study by Chandra et al. at All India Institute of Medical Sciences, India. Our mean application interval was long if compared with 14 days in the USA and 21 days in Sweden., Among the high- and low-risk group no statistically significant observation was found, although there was a delay in the application in about 80.56% cases compared to 64.29% in the low-risk group.
Different application intervals in series may result from demographic characteristics of the patients. It is known that the length of this interval may be associated with several factors. Age, sex, educational level, economic status, and initial symptom may affect the application interval.
Further analysis of categorical variable in assessing application delay, it was shown that in delay group male population was about 76.32% and in no delay group was 58.33%. No statistical significance was found in this association and probably it is due to the fact that the overall age-adjusted lung cancer incidence is still higher in men than women in India. In the case of smoking about 73.68% of cases were smoker in the delay group where 53.33% was nonsmoker. Although no statistical significance was found, this corresponds to the male predominant smoking pattern in India.
The level of education and knowledge awareness about lung cancer has a significant impact on the application interval as per our study. In a similar study by Ebru Sulu et al. in Turkey, it was concluded that prehospital delays are largely dependent on the level of patient education and complex socioeconomic factors. Lower educational attainment was associated with delayed referral in this group, as it was for patients with symptoms of lung cancer. No statistically significant relation was found between rural and urban population among the delay group in our study. It corresponds to the study by Smith et al. in Scotland where on univariate analysis, neither deprivation nor rurality was significantly associated with time to consultation which was confirmed after adjustment for other significant variables in both models.
In our study, among the delay group, the most common symptom was a cough wherein no delay group, it was chest pain, and this association showed statistical significance. Most important patient-related delay as highlighted in Ruchi Sachdev et al. in an Indian study is procrastination and appears to reflect global literature. These patients may be asymptomatic at first; later, may ascribe respiratory symptoms (a cough, coughing up phlegm, shortness of breath, chest pain, etc.) to smoking, a preexisting broncho-pulmonary condition, acute respiratory disease, or even to the lack of rest or aging. This corresponds to the fact that a cough was neglected by most of the patients in delay group in our study where chest pain leads to early consultation to doctor.
In a study by Buccheri et al. concluded that seeking medical advice for an unexplained cough or for a respiratory infection was a sign of a better ultimate outcome, independent of all the other prognostic factors.
The British Thoracic Society recommends that all patients should be seen for an initial evaluation by a pulmonary physician within 1 week of referral from their primary care physician. Diagnostic tests should be performed within 2 weeks of the decision. The Swedish Lung Cancer Study Group recommends that in 80% of all patients, diagnostic tests should be completed within 4 weeks of consultation by a specialist and treatment should be started within 2 weeks thereafter. In Canadian recommendations, a maximum 4-week elapse could be accepted between the first visit to a general practitioner and diagnosis, and the waiting time for surgery should not exceed 2 weeks.
The mean referral interval in our study was 39.60 days ± SD 26.89 (range 2–160). In analysis of possible factors influencing referral delay, it was found that initial diagnosis made by primary care physicians among the delay group were of pulmonary TB in 25.71% and respiratory infection in 17.14% cases. Initial diagnosis of lung cancer was suspected in only 2 cases among the no delay group.
Ebru Sulu et al. in their study concluded that a low index of suspicion for lung cancer was the most common cause for referral delay. Koyi et al. in a prospective study taking 134 cases concluded that a high index of suspicion among the general physicians and a low threshold for referral is important, and a defeatist attitude toward lung cancer may cause a subconscious tendency to avoid diagnosing lung cancer.
Regarding initial radiology NICE clinical guideline recommends urgent referral for a chest X-ray should be made when a patient presents with: Hemoptysis or any of the following unexplained persistent (lasting more than 3 weeks) symptoms and signs: Chest and/or shoulder pain, dyspnea, weight loss, chest signs, hoarseness of voice, finger clubbing, cervical and/or supraclavicular lymphadenopathy, cough with or without any of the above features suggestive of metastasis from lung cancer (e.g., in brain, bone, liver, or skin). A report should be made back to the referring primary healthcare professional within 5 days of referral. In our study, in majority of cases, both in delay group (68.57%) and no delay group (66.67%), chest X-ray was done and thus no conclusion could be drawn between delay in referral and presence/absence of chest X-ray from our study.
However, in our study, significant relationship was found between delays in referral and treatment with anti-tubercular drugs. Among the referral delay group, 45.71% cases were treated with anti-tubercular drugs. Chandra et al. in an Indian study concluded that in developing countries like India, main referral delay is a misinterpretation of chest radiograph findings and starting antitubercular treatment for suspicious opacities on chest radiograph without proper evaluation using appropriate investigative modalities such as CT scan, sputum cytology, and bronchoscopy. Vikash Kumar Singh et al. in an Indian study at AIIMS, New Delhi has proposed that the best and cost effective way to reduce errors will be to investigate all patients suspected of TB and having risk factors for lung carcinoma with 3 sputum AFB as well as sputum cytology for M cells. Current RNTCP guidelines, which are being followed in DOTS Centers across India does not detail about the management for poor response to anti-TB treatment (ATT) in sputum negative pulmonary TB. Hence, they proposed reviewing the diagnosis if no or poor response to the therapeutic trial of ATT at 5 weeks in sputum negative pulmonary TB cases, 85% of patients would have benefited in the form of early diagnosis of lung cancer in case series.
Another factor that showed significant association with the referral delay in our study was advice of CT thorax. CT thorax was not advised in 74.28% cases in the referral delay group. Lack of utilization of this diagnostic modality can be attributed to high cost and limited availability in big cities and Tertiary Care Centers in developing countries. Vikash et al. in a study in AIIMS, New Delhi concluded that any patient with suspected mass on chest X-ray should undergo CECT chest as missing a diagnosis of malignancy is less likely on CT and any atypical presentation or mass should have tissue diagnosis. Patients with known or suspected lung cancer should be offered a contrast-enhanced chest CT scan to further the diagnosis and stage the disease. The scan should also include the liver and adrenals.
Interval at the tertiary center includes waiting times for tests in secondary care, further investigations of symptoms in secondary or specialist care, and administration. In our study, the overall mean interval was 15.06 days ± SD 8.027 (range 5–40) [Figure 2].
Among the no delay group in the tertiary center in 83.33% cases final diagnosis was done by a CT guided FNAC/tru-cut biopsy, whereas in the case of delay group, in the tertiary center, final diagnosis was made by CT-guided procedure in only 15% cases. In delay at tertiary center group, final diagnosis was done in 25% cases by fibreoptic bronchoscopy and biopsy/TBNA, 40% cases by pleural biopsy ± IHC, 15% cases by lymph node biopsy ± IHC and even thoracotomy was required in one case. Significant relationship was found between delay group and number of diagnostic modality used. All delay in tertiary center cases, more than one diagnostic modality was used to reach a final diagnosis. In the histological diagnosis, 56.67% of cases were squamous cell carcinoma; 36.67% cases were adenocarcinoma; and 6.66% of cases were small cell carcinoma, whereas in the no delay group, 50% of cases were adenocarcinoma; 45% of cases were squamous cell carcinoma; and 5% of cases was small cell carcinoma. Given that most patients are admitted to tertiary care with a well-founded suspicion of diagnosis, and considering the availability of specialized, highly-skilled services in these facilities, mean time to confirm NSCLC diagnosis has been estimated at 7–10 days in various international studies. However, this study found that mean length of diagnostic delay at the tertiary level was somewhat longer, although very similar to that reported by other authors in studies done at this level of care in Spain. In our institution, this situation may be mainly due to delays in obtaining histopathology results of invasive procedures such as bronchoscopy and pleural biopsy, especially in cases where IHC was required to confirm the diagnosis. Appropriate test for histological diagnosis of lung cancer must be based on location of the lesion and an adequate sample taken for biopsy, IHC, and marker study.
In our study, mean total time to diagnosis was 146.6 days ± 47.33 (range 45–240). Application delay status had a significant impact on the total time to diagnose [Figure 3]. In a study by Chandra et al. in New Delhi, the median symptom to diagnosis delay was 143 days (range 4–721). Globally, the overall length of diagnostic delay (mean) in lung cancer patients has been estimated at 60–90 days.
Our study had some limitations like sample size were small and may not have been powered adequately for several subgroup analysis and therefore, the results need to be confirmed in a larger study. Most of the data on delay intervals were collected from the interview and medical records review and with limitations accompanying a retrospective study.
| Conclusion|| |
To conclude, there was significant delay between patient's appreciation of symptoms of lung cancer and its ultimate diagnosis. Major factors causing application delay were patient's level of education and awareness about lung cancer. Not doing CT thorax at appropriate time was the main factor for referral delay. So in developing strategies for early diagnosis of lung cancer, awareness programmes for patients and judicious use of diagnostic modalities by physicians should be emphasised so that both application and referral delay can be significantly reduced.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]