Guidance for clinical practice
- Delays in early cancer diagnosis and treatment can lead to devastating consequences.
- Patient engagement and education are key in achieving treatment adherence.
- Nurses’ knowledge and expertise help to improve patient health-seeking behaviors, which aid early cancer diagnosis and treatment.
Learning Objectives
- Describe factors that can delay treatment and impact health outcomes.
- Explain how nurses can facilitate timely patient care via therapeutic communication.
- Describe therapeutic communication techniques that can help patients better understand the value of timely diagnosis and interventions.
No relevant financial relationships were identified for any individuals with the ability to control content of the activity.
Expiration: 4/1/28
Delays in seeking treatment frequently lead to poor health outcomes. Especially with regard to symptoms associated with cancer, early detection and treatment can improve survival rates and quality of life. According to the World Health Organization, colorectal cancer is the third most common cancer worldwide and the second leading cause of cancer-related deaths globally. Fu and colleagues assert that an association exists between treatment delays and advanced disease at time of diagnosis, higher morbidity and mortality risks, loss of productivity, and increased healthcare costs.
Several factors can influence delayed treatment. Understanding why patients may delay seeking care can help nurses engage with, educate, and advocate for patients so they can make informed healthcare decisions.
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Treatment delays and overall patient outcomes
Much research exists about the effects of treatment delays in cancer care and the factors associated with lack of care and negative health outcomes. A meta-analysis by Hanna and colleagues explored the effects of delays in curative cancer treatment on mortality rates. Their examination of 34 studies between 2000 and 2020 showed a positive correlation between increased treatment delays and higher mortality rates. The meta-analysis found that cancer death rates increased between 6% to 8% per every 4 weeks of surgical delay. Delays in curative treatment invariably resulted in increased risk of death.
A study by Nieminen and colleagues showed, in addition to increased risk of death, an association between marked delays in cancer treatment and tumor growth, disease advancement, and poor prognosis. The researchers explored treatment delays in a cohort of 83 patients from 2016 to 2018 and the effect on cancer diagnosis rates and disease management. Data collected from patient questionnaires and hospital records demonstrated a median treatment delay of 30 to 54 days. Longer treatment delays were associated with slow-growing tumors and mild symptoms. However, increased delays also were associated with greater morbidity and mortality risks.
Advanced cancer and metastatic disease can potentially affect a patient’s functional abilities. According to Fu and colleagues, locally advanced cancer and metastatic disease can impact patient function and result in increased morbidity risks. They described patients with longer treatment delays who experienced weight loss, difficulty breathing, incontinence, and swallowing issues, which led to decreased quality of life.
In addition, advanced disease increases morbidity risks and premature mortality with significant impact on healthcare costs and higher productivity losses. Fu and colleagues described how cancer can advance to later stages in as little as 4 to 6 weeks, resulting in increased complexity of care and higher costs. For example, they reported that disease progression in breast, colorectal, and lung cancers accounts for an additional $50,000 per case annually. The authors point out that an advanced disease state associated with treatment delays frequently requires more complex surgeries and more intense and costly treatments. They also noted that an association exists between surgical delays and more advanced disease at the time of surgery as well as greater healthcare costs; for example, between $7,000 to $17,000 per case in patients undergoing colon and lung resections.
Common treatment delay influences
A retrospective cohort study by Sheni and colleagues explored the predictive factors for cancer treatment delays. The researchers, who looked at 2,543 patients in a single cancer center between January 2019 and December 2021, found that in-patients who received treatment within less than 30 days of diagnosis experienced better outcomes compared to outpatients who sought cancer treatment 30 days or more after experiencing the onset of symptoms.
Lack of awareness
A cross-sectional study by Soh and colleagues conducted from January 2020 to October 2020 among female patients with new breast symptoms aimed to identify factors associated with treatment delays. Most of the patients (61.3%) presented to the clinic a month after symptom onset. The perception that the symptoms weren’t dangerous was the main factor associated with delayed care. These findings are consistent with the study by Nieminen and colleagues, which found that lack of awareness about cancer symptoms served as the primary factor associated with delays or lack of treatment.
Mental illness
Mental illness also can play a role in cancer treatment delays. A retrospective case controlled study by Céspedes and colleagues indicated that patients with mental illness (such as schizophrenia, bipolar disease, and depression) had an increased risk for advanced-stage cancer diagnosis. According to their study, patients with colorectal cancer and mental illness had a 4.86-fold higher probability of advanced disease at the time of diagnosis compared with patients without mental illness.
Healthcare system complexity
In addition, healthcare system complexity has been associated with treatment delays. A literature review by Lubuzo and colleagues aimed at identifying key elements to improve cancer care found that complicated referral systems presented a barrier to care. Poor communication among providers and patient challenges related to making appointments appeared to lead patients to give up seeking care, which delayed treatment and resulted in lower survival rates and decreased quality of life.
Politi and colleagues examined root cause analysis reports at the Veterans Health Administration to identify avoidable factors in patient treatment delays. They found a lack of standardization in policies and procedures as well as inconsistencies in following policies. According to the researchers, multiple variations in processes and procedures, as well as poor communication among staff, led to inconsistent patient care and unnecessary delays.
Case study: Treatment delays in action
Mr. Raymond Sanford*, a 67-year-old patient who’s self-employed and divorced with two children, has a medical history significant for myocardial infarction (MI), left heart catheterization, and coronary stent placement. He hasn’t seen his cardiologist in 3 years. Mr. Sanford has hypertension and is a former 40-year pack smoker. In addition, he has alcohol use disorder, chronic obstructive pulmonary disease, residual loss of peripheral vision due to a stroke, chronic hepatitis C, anxiety, and depression.
Mr. Sanford has experienced rectal bleeding for 2 years with changes in bowel function. However, he dismissed the symptoms because of a past history of Helicobacter pylori infection. When he eventually sees his primary care provider, they perform a fecal occult blood test (FIT), which comes back with a positive result. The provider refers Mr. Sanford to a gastroenterologist for a colonoscopy. However, despite the positive FIT results and multiple attempts, Mr. Sanford can’t schedule an appointment with the gastroenterologist.
Eighteen months after the positive FIT, Mr. Sanford returns again to his provider with complaints of blood in the toilet and on tissue paper. The provider states, “I think he may have hemorrhoids.” Mr. Sanford has lost 20 pounds, which he attributes to intermittent fasting. A long overdue colonoscopy finds a circumferential sigmoid colon mass consistent with cancer. Mr. Sanford must undergo a colon resection for stage IV highly invasive sigmoid adenocarcinoma.
I meet Mr. Sanford during a preoperative evaluation for his colon resection surgery. His cardiac workup reveals left atrial enlargement and possible anteroseptal infarct with reduced cardiac function of 45% to 50%. Abnormal cardiac findings in the setting of prior MI and lack of cardiac follow-up for 3 years calls for further cardiovascular testing and cardiac clearance.
After I complete the evaluation, I tell Mr. Sanford, “Everything is almost ready for your surgery. We will need a stress test and cardiac clearance so we can proceed.” He stands up and says, “What do you mean I need to see a cardiologist? I feel fine. You know I can go anywhere to get this surgery done!” He’s reluctant to have more testing; he feels ready to have surgery.
After the delayed cancer diagnosis and treatment, Mr. Sanford faces advanced colorectal cancer, which has nearly obstructed his colon and requires a palliative stent to avoid complete bowel obstruction. In addition, body scans show evidence of distant cancer metastasis with lesions on his liver and reactive lymph nodes. The odds are against him.
Mr. Sanford has already been through multiple tests and procedures to ameliorate the effects of his advanced cancer, which have physically and mentally exhausted him. I listen to Mr. Sanford and encourage him to share his feelings and ask questions. I explain the steps in getting ready for surgery and reassure him that we’re taking all the measures available to ensure he’s comfortable, cared for, and safe.
I speak to the rest of the surgical team about Mr. Sanford’s feelings and how to better meet his needs. We aim to expedite cardiac testing so he can promptly undergo cancer curative surgery.
Case study analysis
The study by Sheni and colleagues found that the main factors involved in treatment delay included multiple medical comorbidities, socioeconomic disparities, lack of health insurance, lack of care coordination, treatment nonadherence, and multiple medical comorbidities.
Consistent with research findings, Mr. Sanford represents a patient with a complex health history and multiple comorbidities who experienced intermittent episodes of rectal bleeding that he dismissed as benign. Although long overdue for a colonoscopy, the provider postponed it after an episode of rectal bleeding attributed to hemorrhoids. Two years of delayed care resulted in advanced colorectal cancer, palliative treatment, and decreased chances for survival.
Socioeconomic factors also may have contributed to Mr. Sanford’s treatment delay. As a divorced, self-employed worker with two children, perhaps he didn’t have the support system to care for his children and family or the time to tend to his health and attend follow-up appointments. Fear of loss of revenue (especially if he didn’t have health insurance) certainly could have played a factor in preventing him from seeking early care.
By the time Mr. Sanford had the colonoscopy, his cancer had advanced. As we prepared him to have the colon cancer removed and potentially begin curative treatment, lack of information about what to expect left him fearful and anxious about the outcome of surgery and his prognosis. The team needed to address his feelings and help allay his fears so he could participate in his care. As a team, we engaged Mr. Sanford so he could complete testing and follow up at the cardiology clinic. Within days, we had him scheduled for a stress test and cleared by the cardiologist to undergo surgery.
As we explore this case scenario, we can identify gaps in patient communication as an important factor in Mr. Sanford’s delayed care. He told his provider on several occasions about the rectal bleeding; however, follow-up didn’t occur. In addition, no effort was made to ensure he understood his disease process and the importance of complying with medical care. However, after we educated him about why he needed further testing as well as risks and benefits, he appeared more at ease and willing to follow through with our recommendations.
Ultimately, Mr. Sanford had surgery to remove the colon cancer and he was expected to undergo chemotherapy to increase his odds for survival. We recommended that he continue to actively engage in his care, adhere to medical advice, and make positive lifestyle changes to decrease his overall health risks. Creating opportunities for Mr. Sanford to talk about and identify factors associated with nonadherence, no show-appointments, and treatment delays helped the team better meet his healthcare needs.
Nursing implications
Nurses can facilitate timely patient care via therapeutic communication (including the use of communication tools), care coordination, and education.
Therapeutic communication
Therapeutic communication can facilitate and improve patient care. According to Potter and colleagues, the effective use of therapeutic communication enhances a patient’s willingness to share feelings, thoughts, and needs while also conveying acceptance and respect. (See Therapeutic communication tips.)
Therapeutic communication tips
Mr. Sanford’s case illustrates the importance of therapeutic communication in facilitating patient care and optimal outcomes. Potter and colleagues describe therapeutic communication as a “healing relationship between a nurse and patient,” which allows nurses to respect patients’ uniqueness and healthcare expectations. It serves as a key to preventing treatment delays. Consider the following suggestions when implementing therapeutic communication.
- Accept. Sometimes you’ll want to simply acknowledge what a patient says and confirm that you’ve heard them. Acceptance doesn’t equal agreement. Making eye contact with the patient and saying, “I understand,” will help them feel heard and taken seriously, which may encourage them to accept care.
- Actively listen. Use nonverbal (nodding) and verbal (saying, “I see”) cues to encourage patients to keep talking. Show interest in what the patient says, let them know that you understand, and engage with them (“What happened next?”) to keep the conversation moving forward.
- Confront. Use this technique only after you’ve established trust with the patient. Sometimes disagreeing, presenting reality, or challenging assumptions can help patients break out of damaging patterns or better understand their situation.
- Encourage comparisons. Drawing upon experience and making comparisons can help patients better manage and discover solutions for current situations.
- Encourage descriptions of perception. When a patient experiences a sensory issue or hallucination, ask them, without judgment, to describe what they’re experiencing. Asking, “What do you hear now?” or “What does that look like to you?” encourages the patient to explain their experience and doesn’t express any negativity.
- Focus. Sometimes patients mention something important without realizing it. When this happens, prompt the patient to keep talking about it. As an impartial observer, you’re well-suited to notice and focus on these critical points.
- Give recognition. Rather than giving a compliment, which can sometimes come off as condescending, offer recognition for adherence. For example, saying, “I noticed you took all of your medications” notes and encourages the action but isn’t a compliment.
- Make observations. Observing and mentioning a patient’s appearance, demeanor, or behavior can help highlight potential problem areas. For example, mentioning that a patient looks tired may prompt them to tell you that they haven’t been sleeping well.
- Offer hope and humor. Find moments to provide hope to patients and share humor. Both can help patients persevere through difficult diagnoses and treatments.
- Offer yourself. Try to find time to sit with patients, even if it’s just to chat with them briefly while they eat a meal. Sharing a bit of your time can help build rapport and boost a patient’s mood.
- Place events in time or sequence. Asking a patient to describe the order of an event may help them remember something important they might otherwise have overlooked.
- Provide broad openings. Effective therapeutic communication occurs when patients decide what to talk about. Give them broad openings, such as, “What’s on your mind today?” or “What would you like to talk about?”
- Reflect. When a patient asks you what they should do, ask them what they think would be the best course of action. This encourages patient accountability and problem-solving.
- Seek clarification. To ensure you understand what a patient has said, ask for clarification (“I’m not sure I understand. Can you explain it to me?”) In addition to helping you, this technique also can help them process their ideas and thoughts.
- Summarize. When you summarize what a patient has said, you let them know that you’re listening and also allows you to document the conversation. When you end the summary with, “Does that sound right,” you give the patient permission to make corrections.
- Use silence. Silence allows you and the patient to process what comes next in the conversation. It also gives the patient an opportunity to bring up a new topic. Always let the patient break the silence.
- Voice doubt. Use this gentle approach to call attention to a patient’s incorrect ideas or perceptions. When you express doubt, help the patient examine their assumptions.
Source: Ernstmeyer K, Christman E, eds. Nursing: Mental Health and Community Concepts. Open Resources for Nursing. Eau Claire, WI: Chippewa Valley Technical College; 2022. ncbi.nlm.nih.gov/books/NBK590040/
The quality of nurse–patient communication can have a direct effect on patient treatment adherence and overall health outcomes. Active listening skills help maintain open communication and promote a trusting nurse–client relationship. Therapeutic communication also facilitates a patient’s problem-solving skills and helps identify patient needs. As nurses, we must remain sensitive to patients; sometimes, that means silence and respecting a patient’s desire not to talk. Ideally, we provide hope and empathy specific to each patient’s situation.
Research supports the use of clinical tools to facilitate communication among nurses and optimal patient outcomes. Politi and colleagues suggest the use of standardized checklists and protocols to guide clinical practice, improve patient outcomes, and reduce variations within clinical and surgical care.
SBAR (Situation, Background, Assessment, and Recommendation), for example, focuses on relevant information to facilitate communication among nurses, prevent errors, and avoid treatment delays. Abbaszade and colleagues describe effective nursing communication during handoff as promoting patient safety and enhancing patient care. Their study evaluated the effectiveness of SBAR use during nurse handoff, which demonstrated a significant increase in communication quality among nursing staff.
Care coordination
Nurse participation in care coordination offers another opportunity to improve patient care. By reducing referral delays, care coordination can lead to early cancer diagnosis and better outcomes. Patients may encounter difficulties accessing care when seeking specialists and ultimately give up and delay care. Nurses can use care coordination to help patients comply with medical care and follow-up appointments. Through care coordination, nurses also can communicate with other members of the healthcare team, acting as patient liaisons to facilitate patient care. Care coordination avoids duplication of services, increases communication and efficiency, and reduces referral delays.
Education
Patient education promotes treatment adherence. A retrospective, cross-sectional study by Tumwijit and colleagues examined the predictors of prehospital delays on patients with colorectal cancers. Those with more knowledge about their disease demonstrated better adherence to medical care compared with patients with less knowledge who tended to delay seeking care. These findings demonstrate the need for nurses to focus on health education, identify disease perceptions, and encourage patient health-seeking behaviors to foster engagement and early cancer diagnosis and treatment.
Make a difference
Nurses have a pivotal role to play in enhancing patient awareness of the importance of early cancer screening and timely follow-up of cancer symptoms. We’re frequently the first line of contact between patients and providers. Patients rely on us to care after them and serve as their voice. With the help of evidence-based practices, we can make a difference in the care of patients like Mr. Sanford.
*This case study is based on actual events. Names and identifying details have been changed to protect patient privacy. The views expressed in this article don’t necessarily represent the views of the Veterans Administration or the U.S. government.
Laura Fontanez is a pre-anesthesia advanced practice nurse practitioner at the Department of Veterans Affairs in Orlando, Florida, and an adjunct nursing professor at Seminole State College of Florida in Sanford.
American Nurse Journal. 2025; 20(4). Doi: 10.51256/ANJ042506
References
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Céspedes P, Sánchez-Martínez V, Lera-Calatayud G, Vila-Candel R, Cauli O, Buigues C. Delay in the diagnosis of breast and colorectal cancer in people with severe mental disorders. Cancer Nurs. 2020;43(6):E356- 62. doi:10.1097/NCC.0000000000000727
Fu SJ, George EL, Maggio PM, Hawn M, Nazerali R. The consequences of delaying elective surgery: Surgical perspective. Ann Surg. 2020;272(2):e79–80 doi:10.1097/SLA.0000000000003998
Hanna TP, King WD, Thibodeau S, et al. Mortality due to cancer treatment delay: Systematic review and meta-analysis. BMJ. 2020;371:m4087. doi:10.1136/bmj.m4087
Lubuzo B, Hlongwana KW, Hlongwa M, Ginindza TG. Coordination models for cancer care in low- and middle-income countries: A scoping review. Int J Environ Res Public Health. 2022;19(13):7906. doi:10.3390/ijerph19137906
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Potter PA, Perry AG, Stockert PA, Hall A. Fundamentals of Nursing. 10th ed. Philadelphia, PA: Elsevier; 2020.
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Soh JY, Yahya MM, Bachok N, et al. Factors associated with delay in seeking carefor breast symptoms. BMC Womens Health. 2022;22(1):316. doi:10.1186/s12905-022-01898-5
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World Health Organization. Colorectal cancer. July 11, 2023. bit.ly/4aDUlZk
Key words: cancer, cancer treatment, treatment delays, survival outcomes
