Delays in diagnosis, referral and management of head and neck cancer presenting at Kenyatta National Hospital, Nairobi.
BACKGROUND: The most important prognostic factor in head and neck cancer is the stage of the disease at presentation. Early cancer has an excellent prognosis following treatment. Unfortunately most patients present with late disease that requires radical treatment with considerable morbidity and mortality. Clinical experience at Kenyatta National Hospital (KNH) shows that most patients present with late disease. OBJECTIVE: To determine the causes of late presentation of head and neck cancer. DESIGN: A prospective descriptive study. SETTING: Kenyatta National Hospital, Nairobi. RESULTS: Forty four cases were seen among whom 34 were males and 10 were females. The age range was 20 to 90 years with a peak incidence between 50 and 60 years. Most of the patients had little or no education and the majority lived in the rural areas. Seventy one percent of the patients came from the Central and Eastern provinces. Tobacco and alcohol use were the most common risk habits. The larynx was the most common site affected followed by the tongue. In 61% of the cases the size of the tumours at presentation was unknown. In 14% the size was 1-2cm, in 7% of the cases it was 2-4 cm while in 5% of the cases it was 4-6 cm. In 14% of the cases the tumour size was over 6 cm. The most common presenting symptom was hoarseness followed by swelling. The majority of the patients attended a public health facility nearest them. For most patients the facility lay within 5 km and could be accessed by walking. However, most of the patients went through multiple referrals to get to KNH. By the time the patients reached KNH, 35 patients (77%) had been treated with unspecified medications, two (4%) had had tooth extraction, and seven (16%) had had biopsies done. The time-lapse between the first symptom and consultation ranged from zero and eight months. Forty five percent of the patients presented to a medical facility within one month of their symptom and 45% presented after three months. The time lapse between referral and attendance at KNH ranged from zero and thirteen weeks and 45% of the patients presented to KNH within two weeks of referral. The overall duration of symptoms by the time of diagnosis ranged from zero months to unspecified years. Thirty two percent of the cases had experienced symptoms for six months or less by the time of diagnosis. However, a number of patients had had their symptoms for a number of years by the time of diagnosis. The distribution of the tumours by stage at the time of final diagnosis were as follows: stage I were 2%, stage II 6%, stage III 14% and stage IV 56%. CONCLUSION: This study showed that the referral system was the main cause of delayed presentation of head and neck cancer to Kenyatta National Hospital.