The sinister significance of dysphagia
The sinister significance of dysphagia MS Grannell, S Kelly, S Shannon, AL Chong, TN Walsh
Abstract Background The majority of patients presenting with oesophageal cancer have symptoms for more than three months and advanced disease at presentation. Most appear unaware of the significance of dysphagia as a symptom. Cancer awareness programmes focus on symptoms such as lumps and bleeding.
Aim To sample the level of public awareness of the potentially sinister significance of the symptom of dysphagia. Methods A community survey was conducted using a questionnaire to evaluate the subjects’ impression of the significance of dysphagia, and compare it with their perception of the significance of breast lump. Patients were stratified to male and female, under and over 45 years.
Results There were 164 subjects interviewed. Seventy-five per cent stated that they would visit their doctor within one week of developing dysphagia compared with 87 per cent questioned about a breast lump (96 per cent females, 80 per cent males). Only 17 per cent felt that cancer was a probable explanation for dysphagia compared with 80 per cent who would consider cancer a likely cause of breast lump.
Conclusion There is evident need of an awareness programme of the potential significance of dysphagia if prognosis for oesophageal cancer is to be improved
Introduction The incidence of oesophageal carcinoma is increasing worldwide and Ireland ranks seventh in terms of rate of increase.1 Over 400 new cases of carcinoma of the oesophagus and cardia are diagnosed in Ireland each year.2 This increase in incidence is largely due to an increase in the incidence in adenocarcinoma.3-5 While the overall mortality from resection has nearly halved in the last decade,6,7 the long-term prognosis has not changed1 and is at best 10 per cent.8 The poor results of treatment reflect the advanced stage at presentation with a systemic spread in over 80 per cent.9 This may be partly attributed to delay in diagnosis.10 The reasons for delay are many. A previous study suggested that patients had a poor awareness of the significance of dysphagia, but that family doctors and hospital admission systems for endoscopy are also to blame.10 There are no studies examining public perception of dysphagia as a symptom or of its potential significance. The aim of this study was to document the public perception of dysphagia, its possible causes and how it should be managed.
Methods A questionnaire was designed to evaluate a subject’s impression of the significance of dysphagia. This was compared with their perception of the significance of other readily recognisable symptoms. The information sought was urgency of medical advice, options for care and the probable cause of the symptoms. Subjects were stratified in to male and female, under and over 45 years.
Administration of questionnaire The study was undertaken by a group of non-consultant hospital doctors who interviewed pedestrian subjects in a busy city centre street. Four questions were asked: 1. How soon would you see your GP for the following presenting complaints: breast lump; dysphagia? The options were within a day, within a week, within a month or not at all. 2. What do you think is the likely cause of the following presenting complaints: breast lump; dysphagia? The options were infection, injury, cancer or other? 244
3. What treatment would you expect for the following presenting complaints: breast lump; dysphagia? The options were medication, surgery or no treatment. 4. Would you expect your GP to refer you to a specialist for the following presenting complaint: breast lump; dysphagia? The options were yes or no.
Data analysis Data was collected and analysed on a Microsoft Excel spreadsheet. Data is expressed as mean±standard error of mean (SEM).
Results One hundred and sixty-four people were interviewed. There were 44 (27%) males under 45 and 30 (19%) males over 45. There were 48 (29%) females under 45 and 41 (25%) females over 45 (see Table 1). Urgency of symptoms Seventy-five per cent of all people interviewed would seek medical advice within one week of developing dysphagia. This compares to 87% who would seek medical advice within one week of finding a breast lump. Eighty-two per cent of all males would visit their GP within one week of developing symptoms of dysphagia. However only 68% of all females interviewed would visit their GP within one week of developing dysphagia. This compares to 95% of all females who would visit their GP within one week of finding a breast lump. Ten per cent of all males and 16% of all females would not visit their GP at all if they developed dysphagia. Probable cause of symptoms Only 17% of all those interviewed felt that dysphagia could be due to a tumour compared to 80% who felt that a breast lump could be due to cancer (p45 45 30 1. Would seek medical advice for Dysphagia 1 week 7% 7% No advice 15% 3% Breast lump 1 week 15% 0% No advice 13% 7% 2. Probable cause of: Dysphagia Infection 64% Cancer 8% Breast lump Infection 9% Cancer 75% 3. Expected treatment for Dysphagia Medication 78% Surgery 15% Breast lump Medication 18% Surgery 82% 4. Specialist referral for: Dysphagia Yes 31% Breast lump Yes 87%
Females ≤45 >45 48 41
62% 23% 15%
76% 7% 17%
96% 2% 2%
93% 0% 7%
Probable treatment required Most expected medication for the treatment of dysphagia (67%). There was no difference between both groups, 72% of males versus 65% of females. The majority of males and females expected surgery for breast lumps (83%), 81% of males versus 83% of females over 45 and 8% of females under 45. Need for specialist referral Few expected referral to a specialist for dysphagia (39.5±7.1), 40% of all males versus 36% of all females. Most expected referral to a specialist for a breast lump (89%), 87% of all males versus 92% of all females.
Discussion This is the first study to investigate the public perception of dysphagia as a symptom and the findings show that the general public appear largely unaware of its potential sinister significance. This lack of awareness is consistent with the findings of a previous study in which the majority of patients with oesophageal cancer presented with symptoms for more than three months,10 albeit in that study over 50% of this delay was out of patients control. Health promotion campaigns and hospital-based programmes have clearly had an impact on the awareness of the significance of breast lumps. The great majority of females (96% under 45 years of age and about 80% over 45) would visit their family doctor within one week of finding a breast lump. This is also borne out in breast clinic data. By comparison, 82% of males and 68% of females said that they would visit their GP within one week of developing dysphagia. This is at variance with reality, however, as the majority have symptoms for three months or more.10 Irish Journal of Medical Science • Volume 170 • Number 4
Only 17% of those interviewed considered malignancy as a possible cause for dysphagia compared with 80% of females who considered cancer as a possible cause for a breast lump. This reflects the effectiveness of cancer awareness initiatives in the media, augmented by the introduction of the National Breast Cancer Screening Programme in Ireland in 2000. The majority of females expect referral to a specialist for further assessment and also expect surgery for treatment of breast lumps reflecting a basic level of knowledge regarding breast lump management. There has been no oesophageal cancer awareness programmes. It is evident from these results that there is little awareness of the possibility that dysphagia may be due to a malignant cause. Earlier clinical presentation is essential if treatment is to be successful and the prognosis improved. It is unclear from the literature whether presentation when symptoms first develop would improve outcome. A previous study failed to show a significant difference in outcome between those who presented earlier and those in whom presentation was delayed.10 This may have been due to a type 2 error as the number who presented early was small. It is clear, however, that patients who are diagnosed on surveillance programmes for Barrett’s mucosa have a superior outcome to that of symptomatic patients.11 Oesophageal cancer does not fulfil the criteria to warrant a screening programme, yet it should be remembered that while cancer of the oesophagus and stomach has an incidence of only 50% that of breast cancer it is responsible for a similar number of deaths. Cancer of the oesophagus kills a similar number of subjects as are killed on the roads each year. An awareness programme is essential if an improvement in these dismal statistics is to be brought about.
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