In this study, we observed that 13.9% of patients with gastric cancer obtained follow-up evaluation more than 90 days, even though they were told that they needed medical services for diagnostic confirmation and treatment because their screening results were suspicious for cancer or indicated cancer. Age, health-insurance type, screening method, and screening results were risk factors for follow-up delay. Specifically, the 90-day follow-up rate was lower among individuals over 70 years of age, recipients of Medical Aid, individuals with a suspicious results, and those who underwent UGIS compared with individuals who were younger, NHI beneficiaries, individuals with results indicative of cancer, and those who underwent endoscopy, respectively.
These results are consistent with reports from previous studies that cancer screening follow-up delay varies by age and income
[4, 14–17]. The follow-up delay among individuals aged 70 or over may be due to reluctance to follow the physician’s recommendation to seek diagnostic confirmation or treatment. It may also be more difficult for elderly individuals to understand the need for follow up or to follow up within an appropriate period of time. In the current study, Medical Aid recipients were also less likely than NHI beneficiaries to have an appropriate follow-up period, even though recipients of Medical Aid who participated in the NCSP for gastric cancer and was subsequently diagnosed with gastric cancer through the program would be supported financially through the Financial Aid Program. This indicates financial or other barriers may affect recipients of Medical Aid despite free-of-charge cancer screening and the Financial Aid Program for treatment. These people may be dealing with other issues, including difficulty in accessing facilities and multiple personal and cultural barriers to choosing to undergo follow-up evaluations
. Participants who underwent endoscopy may have responded more rapidly to abnormal results because they believed endoscopy to be more accurate than UGIS in detecting gastric cancer
The literature contains no consensus about the definition of a “reasonable” follow-up interval after an abnormal screening result for gastric cancer. Some investigators have found that follow-up intervals of up to 3 months may not impact overall survival from breast or colorectal cancer, whereas others have shown that women who waited more than 30 days for evaluation after the detection of breast cancer were more likely to experience cancer recurrence or death
[4, 14, 19]. The general perception among patients, health professionals, and politicians is that delay has a definitely unfavorable effect on outcome
[7, 11, 12, 20–22].
The cancer-care-continuum disparities model begins with prevention and early detection and continues through the survival period. Several of the factors that may contribute to cancer disparities may occur at each end of the continuum or at the stages in between, such as diagnosis and treatment
[14, 18, 23, 24]. This study was unable to address the long-term clinical significance of the delay in follow up after an abnormal gastric cancer screening result; however, similar differences at other points along the cancer-care continuum may have a cumulative clinically significant overall impact on mortality. Inadequate follow up of abnormal exam results undermines the potential benefits of cancer screening
. An organized cancer screening program is one of many interventions for reducing disparities in the cancer-care continuum. Services from cancer screening to treatment need to be organized so that delays are minimized. Improvements in the diagnostic and treatment process should be achievable, particularly for those whose delays were longest. The design of tailored and targeted interventions such as campaigns directed at specific age groups and social classes may help to reduce these delays. Interventions should involve the local community and should be related to each aspect of the aforementioned barriers that may contribute to delays in follow-up.
Several European countries with strong primary healthcare systems, such as the United Kingdom and Denmark, have developed organized cancer screening systems to reduce the time for the diagnosis and treatment of cancer. National fast-track referral guidance has also recently been introduced. Suspicion of cancer leads to prompt referral of the patient to a specialist for assessment and initiation of a progressive diagnostic program that is conducted within a limited time frame
In the context of a gastric cancer screening unit, the absence of the sort of close relationship or continuous connection that exists between primary physicians and patients may have affected the long follow-up periods found by the current study. The use of primary-physician-based intervention may be a good way to decrease the follow-up time. Additionally, the Public Health Centers in Korea are now primarily responsible for encouraging target individuals to participate in the NCSP. The Public Health Centers need to encourage the public, via telephone or letter, not only to participate, but also to follow up and maintain an appropriate follow-up timeline after an abnormal finding by campaigning. The NCSP needs to develop a quality improvement (QI) infrastructure to implement an effective strategy for improving follow up
Follow-up delay may be affected by knowledge of a malignancy, perceptions of the results as reported in the letter, or access to services
[6, 7]. Sensitive and specific strategies to reduce patient delays, especially those related to knowledge of a malignancy or perceptions of the letter reporting the screening results, should improve awareness of cancer and aid in patients’ interpretation of screening results. Delays may be reduced by crafting letters that present the results in a way that is easily understood by underprivileged participants according to age, education, and income; that provides clear referral guidance or a referral protocol; or that enables access to a well-organized system that facilitates prompt action by participants with abnormal findings.
This study has several limitations. First, we did not have information about beliefs about screening, health literacy, patient–provider communication and relationships, or system failures. It would be useful to collect such information in future studies to enable a more comprehensive analysis of our findings. Second, we had no information about participants who did not use medical services at all. Work is needed to further explore the reasons that patients do not see a doctor at all and to examine the implications of this behavior. Finally, information about stage distribution was not available. It would be informative to compare stage distribution between those who had follow-up delay or not.
Some recent studies in Korea have focused on participation in cancer screening programs, especially organized cancer screening programs
[27–33]. One study suggested that progress had been made toward bridging disparities in organized screening for gastric cancer that were related to socioeconomic status
. However, policy makers have paid little attention to delays or variations in the initiation and completion of treatment until now. This study provides additional evidence of follow-up delay and variations in the time to follow up after an abnormal finding. This information may be used in subsequent analyses to identify barriers that lead to differences in the lengths of such delays. Interventions can then be implemented to address delays between the diagnosis and treatment of gastric cancer.