Commentary: Britain does better than germany before patients reach hospitalBMJ 1997; 314 doi: http://dx.doi.org/10.1136/bmj.314.7079.471 (Published 15 February 1997) Cite this as: BMJ 1997;314:471
It is undisputed that a patient's prognosis is better the earlier the tumour stage is at the start of treatment. It is also undisputed that a tumour grows with time. Delay in the diagnosis of a tumour is therefore counterproductive, but does it also influence the prognosis of a patient?
Delays in diagnosis may reflect the natural course of the tumour, with tumours that have been diagnosed late developing slower than those detected earlier and vice versa. So far there is no clear proof that the extent of delay in the diagnosis is consistent with a worse prognosis. Martin et al found a correlation for oesophageal cancer but not gastric cancer and our own analysis could also not identify such a correlation.1
The specific problem when dealing with gastric carcinomas is that there is no typical symptom which brings the patient to the doctor. Theodor Storm, a German poet who died of gastric cancer, described his symptoms as “only a point, hardly a pain.” Therefore it is understandable and unavoidable that some delay in diagnosis is caused by the patient. Only intensive education of the population and easy access to endoscopy might help to shorten the delay. A patient must have the opportunity to have endoscopy without all the bureaucratic hurdles and with the full freedom of choice of treatment later on. At present this is not possible in Germany. Patients must be referred to a specialist and the cost has to be reimbursed from the patient's health insurance. Obviously open access as described by Martin et al is better.
The importance of open access to endoscopy is proved by the long “doctors' delay.” In Germany the delay is 12 weeks longer than that reported by Martin et al (table 1)). Part of the problem is that a doctor is paid for the patient's treatment and not for the diagnosis. Therefore when a patient presents with epigastric discomfort doctors generally start by treating the symptoms. H2 blockers and especially omeprazol and Helicobacter pylori eradication improve symptoms, and the need for further investigation is reduced or delayed. In Germany the doctor's delay in diagnosis is 11 weeks for a general practitioner but 24 weeks for an internal physician. A reward is needed for the discovery of an early carcinoma to strengthen the motivation of doctors in private practice.
At least in Germany the diagnostic delay stops as soon as the patient enters the clinic. From this point it is only one more week until the final diagnosis is made and treatment started. This is the only point where the situation in Germany is obviously better than in Great Britain, where one third of the time of delay is caused by the last phase in the hospital. In this respect the British system could be improved.