Cancer is a major public health challenge worldwide, and its burden is increasingly concentrated among the elderly population. Globally, more than 60% of new cancer cases and 70% of cancer-related deaths occur in individuals aged 65 years and above, reflecting both increased life expectancy and age-related vulnerability to malignancies^[1]. In India, the elderly account for nearly half of all cancer cases, with projections indicating a sharp rise due to demographic transition and population ageing^[2].

Despite advances in diagnostics and treatment, elderly patients are disproportionately diagnosed at advanced stages of disease. Early symptoms are often nonspecific and misattributed to ageing or pre-existing comorbidities, leading to delays in help-seeking^[3]. Additionally, socioeconomic disadvantages, rural residence, limited awareness, and dependency on caregivers exacerbate delays in accessing medical care^[4]. From the healthcare provider perspective, under-referral, symptom dismissal, and inadequate geriatric-sensitive cancer screening further compound diagnostic delays^[5].

Previous studies across high-income countries have highlighted that system-level factors—such as lack of age-adapted cancer screening, long waiting times for investigations, and high out-of-pocket costs—contribute significantly to late-stage presentations^[6,7]. Indian hospital-based studies have similarly reported that elderly patients often present with stage III–IV disease, with gastrointestinal, lung, and breast cancers predominating^[8,9]. However, limited research has systematically explored the interplay of patient-, provider-, and system-related barriers in the Indian rural context.

Given the rising cancer burden in India’s ageing population, understanding these barriers is critical for timely interventions. Identifying modifiable factors that delay diagnosis can inform targeted awareness programs, streamline referral pathways, and shape elderly-focused cancer screening strategies. This study, therefore, aims to evaluate the demographic, clinical, and healthcare-related determinants of delayed cancer diagnosis among elderly patients in a tertiary care setting in South India.

Aim

To evaluate patient-related, provider-related, and system-related factors influencing delayed cancer diagnosis in elderly patients.

Objectives

1. To assess the demographic, socioeconomic, and clinical characteristics of elderly patients diagnosed with cancer.
2. To identify patient-related, provider-related, and healthcare system-related barriers contributing to diagnostic delay.
3. To analyze the association between these barriers and stage of cancer presentation at the time of diagnosis.

Study Design and Setting This was a cross-sectional observational study conducted in the Department of Oncology at Sree Mookambika Institute of Medical Sciences (SMIMS), Kulasekharam, Tamil Nadu. The study was carried out over a period of 12 months, from ______ to ______. Study Population The study population included elderly patients aged 65 years and above who were newly diagnosed with any type of malignancy and registered at SMIMS during the study period. Patients with recurrent cancers, those who had previously received oncological treatment elsewhere, and those unwilling to participate were excluded. Sample Size A total of 120 patients were recruited using consecutive sampling. The sample size was chosen based on feasibility and comparable figures reported in earlier hospital-based studies evaluating diagnostic delays in elderly cancer patients. Data Collection Tool Data were collected using a pre-tested, structured questionnaire designed for this study. The tool captured socio-demographic details (age, sex, education, occupation, income, and place of residence), clinical variables (type of cancer, comorbidities, stage at diagnosis, and functional status as per Katz Index), and dates of symptom onset, first healthcare contact, and confirmed diagnosis. The questionnaire also included items on patient-related, provider-related, and system-related barriers to early diagnosis, assessed through both multiple-choice questions and Likert-scale responses. Operational Definitions • Diagnostic delay was defined as an interval of more than three months between the onset of first symptoms and histopathological confirmation of cancer. • Early stage referred to stage I and II disease, while late stage referred to stage III and IV, based on TNM classification. • Functional status was assessed using the Katz Index of Independence in Activities of Daily Living. Data Collection Procedure After obtaining written informed consent, participants were interviewed in the outpatient and inpatient oncology units using the questionnaire. Clinical details were verified from patient medical records, pathology reports, and hospital records to ensure accuracy. Ethical Considerations The study protocol was approved by the Institutional Ethics Committee of SMIMS, Kulasekharam. Written informed consent was obtained from all participants. Confidentiality of personal information was maintained, and data were used solely for research purposes. Statistical Analysis Data were entered in Microsoft Excel and analyzed using SPSS version 26 (IBM Corp., Armonk, NY). Descriptive statistics were presented as frequencies and percentages for categorical variables, and mean ± standard deviation for continuous variables. The association between barriers and stage at diagnosis was assessed using the chi-square test or Fisher’s exact test as appropriate. A p-value of <0.05 was considered statistically significant.

Table 1: Socio-demographic Characteristics of the Study Population (n = 120)

Table 2: Clinical Profile and Stage at Diagnosis

Table 3: Patient-Related Barriers to Early Diagnosis

Table 4: Provider- and System-Related Barriers

Table 5: Association Between Barriers and Stage at Diagnosis

In the present study, 70% of elderly cancer patients were diagnosed at an advanced stage (III–IV). This finding aligns with reports from Indian and international studies which have consistently highlighted that delayed presentation is common in older adults. A multicentric Indian study observed that more than two-thirds of geriatric cancer patients presented with late-stage disease, primarily due to misinterpretation of early symptoms and lack of screening facilities[10]. Similarly, a UK-based population study reported that elderly patients had longer diagnostic intervals and higher odds of late-stage diagnosis compared to younger adults[5]. Patient-related barriers were particularly prominent in this study. Half of the participants attributed symptoms to ageing, and 48.3% faced difficulty travelling to healthcare facilities. Misattribution of symptoms has been reported as a common phenomenon in older adults, as shown in a study where older patients often normalized fatigue, cough, or weight loss as age-related changes rather than warning signs of malignancy[7]. Transportation difficulties were also emphasized in rural Bangladesh, where geographical inaccessibility and poor mobility significantly contributed to diagnostic delays among the elderly[11]. Fear of diagnosis and financial constraints were additional patient-level barriers in the present study. Nearly 40% of patients avoided seeking care due to fear of cancer confirmation, while 37.5% reported cost concerns. Similar patterns were described in a South Indian hospital-based study, where stigma, fear of treatment, and out-of-pocket expenses were major deterrents to early consultation[12]. This highlights the dual impact of psychological and economic barriers in shaping health-seeking behavior among older populations. Provider-related barriers such as lack of prompt referral (35%) and dismissal of symptoms (31.7%) were also observed. Previous studies from both high-income and low-middle-income countries have reported comparable trends. Inadequate physician suspicion and referral delays were found to significantly contribute to prolonged diagnostic intervals in elderly cancer patients in Canada[13]. Likewise, in India, short consultation times and a tendency of general practitioners to attribute complaints to benign or age-related conditions delayed cancer detection[14]. System-related challenges were the most striking in the present study, with 60% of patients citing the absence of screening programs, 56.7% reporting long waiting times, and 45% identifying high diagnostic costs. These results mirror findings from India, where the lack of organized cancer screening programs was considered a critical factor leading to late detection, particularly for breast, cervical, and gastrointestinal malignancies[15]. In African settings, long waiting periods for diagnostic procedures and financial inaccessibility were also found to be major bottlenecks in early diagnosis[16]. The association analysis in this study further strengthens these observations. Patient misperceptions (p < 0.001), difficulty in travelling (p = 0.002), high diagnostic costs (p = 0.04), and long waiting times (p = 0.03) were significantly linked to late-stage diagnosis. Comparable statistical associations were described in Germany, where patients with financial limitations, logistic barriers, or low awareness were significantly more likely to present with advanced disease[17]. Taken together, these findings indicate that delayed diagnosis of cancer in the elderly is multifactorial and results from the interplay of individual, provider, and system barriers. The similarity of our findings with previous Indian and global studies underscores the universality of these challenges. However, the predominance of system-related barriers such as long waiting times and absence of elderly-focused screening programs highlights a critical area for intervention in the Indian healthcare context.

This study highlights that elderly cancer patients often face significant delays in diagnosis due to a combination of patient-related, provider-related, and system-level barriers. Misattribution of symptoms to ageing, difficulties in accessing healthcare facilities, financial constraints, and prolonged waiting times for investigations were among the most frequent challenges identified. A majority of patients were consequently diagnosed at advanced stages, underscoring the urgent need for improved awareness, early screening initiatives, and better healthcare accessibility for the elderly population. Strengthening referral pathways and tailoring cancer awareness programs to older adults could play a vital role in reducing diagnostic delays and improving outcomes.

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