Antibiotic Prescribing May Delay Diagnosis of Head and Neck Cancer

Antibiotics are often prescribed in the 3 months preceding a diagnosis of head and neck cancer, resulting in delays in diagnosis, according to a large retrospective cohort study.

In over 7,800 patients with head and neck cancer, at least one antibiotic was prescribed to 15.6% of patients within 3 months before diagnosis, representing an increase over the 8.9% baseline prescribing rate (12 to 9 months before diagnosis), reported Sean T. Massa, MD, of the Saint Louis University School of Medicine in Missouri, and colleagues.

Patients receiving an antibiotic prescription within 3 months of a diagnosis had a 21.1% longer time between symptom onset and diagnosis (adjusted rate ratio [RR] 1.21, 95% CI 1.14-1.29), they noted in JAMA Otolaryngology-Head & Neck Surgery.

That difference increased when symptoms presenting within 6 months (aRR 1.38, 95% CI 1.30-1.47) and 12 months (aRR 1.50, 95% CI 1.42-1.60) of diagnosis were included.

“It is well understood that delayed diagnosis is associated with higher stage at diagnosis and decreased overall survival,” Massa and colleagues wrote. “The issue then becomes the extent of a delay required to negatively affect patient outcomes.”

They noted that a previous study on time to surgery estimated that every 30 days of surgical delay increased the hazard of death in patients with head and neck cancer by 4.6%.

“This highlights that even a few weeks for a course of antibiotics and a second follow-up appointment before referral makes a difference,” they added.

The study authors also highlighted that primary care/internal medicine physicians were most likely to prescribe antibiotics for patients who were diagnosed with a presenting symptom compared with otolaryngologists (adjusted prevalence ratio [aPR] 1.60, 95% CI 1.27-2.02). In addition, patients presenting with neck mass/swelling and other symptoms were more likely to have longer intervals from symptom onset to diagnosis (aRR 1.31, 95% CI 1.08-1.59).

The rate of antibiotics prescribed did not decrease after the American Academy of Otolaryngology-Head and Neck Surgery published evidence-based guidelines recommending against antibiotic prescribing for adults with a neck mass without infectious symptoms in 2017.

Thus, “[f]urther efforts are likely needed to not just produce evidence-based guidelines but also to disseminate this knowledge to the broader medical community,” Massa and team wrote.

However, in an invited commentary, Evan Graboyes, MD, MPH, of the Medical University of South Carolina in Charleston, and colleagues said it is “impossible” to expect primary and urgent care physicians to completely stay abreast of the multitude of clinical practice guidelines.

They suggested that data-driven and technology-enhanced approaches — such as clinical decision support tools within primary care and artificial intelligence platforms such as ChatGPT — could potentially help decrease diagnostic errors.

This study shows that for many patients, “the road from symptom onset to HNC [head and neck cancer] diagnosis should be marked with a sign reading ‘Warning, Detour Ahead,'” Graboyes and colleagues wrote. “It is now incumbent on us to work in a collaborative and multidisciplinary fashion to create a road free of detours for our patients and ensure that these important findings are translated back to decrease morbidity and mortality.”

For this study, Massa and team used data from a de-identified electronic health record dataset from January 2011 to December 2018. Patients had a mean age of 60.2, 53.1% were men, and most had commercial insurance (52.3%), were white (78.6%), resided in the Midwest (62.1%), did not have a diagnosis of metastatic disease (91.1%), and had no unique antibiotic prescriptions 1 year to 3 months before head and neck cancer diagnosis (77.6%).

Compared with white patients, African-American patients (aPR 0.77, 95% CI 0.65-0.92) and non-Hispanic other/unknown race patients (aPR 0.66, 95% CI 0.50-0.88) were less likely to receive antibiotics 3 months before diagnosis.

“That said, patients in minority racial and ethnic categories are still overall diagnosed later and have worse outcomes associated with HNC,” Massa’s group wrote. “While clinician biases may contribute to this factor, it seems more likely related to overall differences in access to healthcare between races and ethnicities.”

The authors acknowledged several limitations to their study, including the fact that the patient sample was non-random and may not be generalizable.

“In addition, some antibiotic prescribing, even related to an HNC diagnosis, may be appropriate to treat infections and thus the associated delays may be related to a true infection rather than a misdiagnosis,” they noted.