Factors associated with delayed diagnosis among Filipino pediatric brain tumor patients: a retrospective review

Figures & data

Figure 1. Selection of included medical records of pediatric patients diagnosed with primary brain tumors from January 2015 to December 2019.

PGH: Philippine General Hospital; PSI: Prediagnostic symptomatic interval.

Table 1. Patient and tumor characteristics (n = 196).

Age at diagnosis (years)
Median	9
Range	1 to 18
IQR	5 to 13
Sex	Number of patients	Percentage
Male	126	64.3
Female	70	35.7
Comorbidities and other illnesses	14	7.1
Respiratory	7	3.6
Autism spectrum disorder	2	1
Attention deficit hyperactivity disorder	1	0.5
Ventricular septal defect	1	0.5
G6PD deficiency	1	0.5
Polycythemia vera	1	0.5
Cellulitis	1	0.5
Tumor-related syndromes	10	5.1
Tuberous sclerosis complex	5	2.6
Neurofibromatosis type II	4	2
Neurofibromatosis type I	1	0.5
Income cluster
Poor	32	16.3
Low to lower middle income	112	57.1
Middle to upper middle income	47	24
Mother’s highest educational attainment
Elementary	12	6.1
High school/vocational	87	44.4
College/post-graduate	56	28.6
Father’s highest educational attainment
Elementary	14	7.1
High school/vocational	78	39.8
College/post-graduate	53	27
Tumor size (volume)
Median	35.2 cm^3
Range	1.5 to 611 cm^3
IQR	18.6 to 60 cm^3
Tumor location	Number of patients	Percentage
Supratentorial	98	50
Cerebrum	36	18.4
Sellar-suprasellar	31	15.8
Pineal	31	15.8
Infratentorial	98	50
Posterior fossa	82	41.8
Brainstem	16	8.2
Tumor grade
WHO grade I	59	30.1
WHO grade II	12	6.1
WHO grade III	1	0.5
WHO grade IV	74	37.8
Histopathology
Medulloblastoma	43	21.9
Low grade glioma	40	20.4
High grade glioma	37	18.9
Germ cell tumors	24	12.2
Craniopharyngioma	14	7.1
Ependymoma	10	5.1
Schwannoma	6	3.1
Pituitary adenoma	3	1.5
ATRT	2	1
Metastasis at diagnosis	3	1.5

ATRT: Atypical teratoid rhabdoid tumor; IQR: Interquartile range.

Table 2. Prediagnostic symptomatic interval.

	PSI 1 (parents delay)	PSI 2 (doctors delay)	PSI 3 (subspecialist delay)	PSI overall
Median	22 days	23.5 days	0 days	80.5 days
Range	0 to 1794 days	0 to 1464 days	0 to 1471 days	0 to 1815 days
IQR	5 to 62 days	5 to 61 days	0 to 5 days	31 to 199 days

IQR: Interquartile range; PSI: Prediagnostic symptomatic interval.

Table 3. Characteristics of the ten patients with prediagnostic symptomatic interval >3 years.

Patient number	PSI in months	Sex	Age at diagnosis (years)	Tumor location	Histopathology	Initial diagnosis	Symptoms at onset	Number of physicians consulted prior to diagnosis ^†	Neurologic deficits upon neurologic subspecialist consultation
066	38.6	F	10	Sellar-suprasellar	Cranio-pharyngioma	No data	Secondary ammenorhea, headache	2	Bitemporal hemianopsia, decreased visual acuity, exotropia of the left eye
095	36.5	F	9	Cerebrum (left temporal)	Ganglioglioma	Epilepsy	Seizure	2	Slowed speech, slow to respond, fair attention
114	48.9	M	13	Pineal	Mixed malignant GCT	Error of refraction	Blurring of vision, poor school performance	6	Nonreactive pupils, bilateral papilledema, parinaud syndrome
124	60.5	M	14	Sellar-suprasellar	Pituitary adenoma	Primary headache	Headache	3	Left temporal hemianopsia, impaired visual acuity, ilateral lateral rectus palsy
127	38.1	M	4	Sellar-suprasellar	Pilocytic astrocytoma	Error of refraction	Blurring of vision, headache	2	Left homonymous hemianopsia, left extremity drift, left lower extremity clonus, nystagmus
137	48.7	F	13	Cerebrum (right frontoparietal)	Ganglioglioma	No data	Left extremity numbness and weakness	2	Lethargy, bilateral pailledema, left central facial palsy, left hemiplegia
146	49	M	11	Cerebrum (left frontal)	Glioblastoma	No data	Headache, seizure	2	Right lateral rectus palsy, fair gutturals, left hemiparesis, nystagmus
167	45.7	F	18	Cerebrum (right temporal)	Ganglioglioma	Anxiety disorder	Behavioral changes (fear and panic)	4	No deficits, (+) seizures
176	48.7	F	18	Sellar-suprasellar	Germinoma	Unspecified gynecologic dysfunction	Secondary amenorrhea, polydipsia, polyuria	4	Light perception on left, right temporal hemianopsia, optic atrophy
191	49.3	M	13	Posterior fossa	Pilocytic astrocytoma	No data	Headache, vomiting	2	Gait ataxia, dysmetria

Symptoms/signs are listed in the order reported or observed.

† Number of physicians consulted prior to diagnosis excludes neurologic subspecialty consults.

F: Female; GCT: Germ cell tumor; M: Male; PSI: Prediagnostic symptomatic interval.

Table 4. Presenting symptoms at onset, during first physician consult, and upon subspecialist consult.

	Median PSI (days)		p-value	Number of patients (percentage) presenting with the symptom			Frequency increase in number of patients presenting with the symptom from onset to subspecialist referral
	Patients with the symptom	Patients without the symptom		At onset	During first consult	Upon subspecialist consult
Headache	84	78	0.620	115 (58.7)	131 (66.8)	137 (69.9)	23
Vomiting	61	102	0.015	76 (38.8)	94 (47.9)	103 (52.6)	27
Gait imbalance/unsteady gait	61	88	0.132	37 (18.9)	61 (31.1)	77 (39.2)	40
Blurring of vision	92	77	0.119	27 (13.8)	43 (22.4)	61 (31.1)	34
Dizziness	75	83	0.961	25 (12.8)	31 (15.8)	33 (16.8)	8
Diplopia	76.5	83.5	0.918	16 (8.2)	27 (13.8)	40 (20.4)	24
Seizure	336	76	0.021	10 (5.1)	21 (10.7)	28 (14.3)	18
Paresis	62	86	0.312	9 (4.6)	22 (11.2)	37 (18.9)	28
Increased sleeping time	61.5	85	0.192	8 (4.1)	18 (9.2)	30 (15.3)	22
Ocular motility dysfunction	68	86	0.530	7 (3.6)	14 (7.1)	38 (19.4)	31
Poor school performance ^†	792	77.5	0.030	8 (4.6)	8 (4.6)	8 (4.6)	2
Behavioral changes	540	77.5	0.018	5 (2.6)	5 (2.6)	5 (2.6)	0
Secondary amenorrhea ^†	365	77	0.037	5 (13.9)	5 (13.9)	5 (13.9)	0
Polydipsia/polyuria	67	83	0.408	5 (2.6)	5 (2.6)	5 (2.6)	0
Hearing loss	92	78	0.559	3 (1.5)	7 (3.6)	11 (5.6)	8
Numbness	91	78	0.708	3 (1.5)	3 (1.5)	5 (2.6)	2
Facial palsy	63	83		3 (1.5)	7 (3.6)	17 (8.7)	14
Torticollis	63	83	0.082	3 (1.5)	6 (3.1)	7 (3.6)	4

† Patients analyzed for these symptoms included only the population at risk. For poor school performance, patients aged 4 years and above (n = 175) were included, based on average age of school entry at 4 years old. For secondary amenorrhea, only females 13 years and above (n = 36) were included, based on average age of menarche for Filipino female of 13 years old.

PSI: Prediagnostic symptomatic interval.

Table 5. Number of symptoms at onset, during first physician consult and upon subspecialist consult.

Number of symptoms at presentation	At onset		During first physician consult		Upon neurology/neurosurgery referral
	Number of patients	Percentage	Number of patients	Percentage	Number of patients	Percentage
1	69	35.2	48	24.5	17	8.7
2	83	42.3	71	36.2	33	16.8
3	31	15.8	38	194	44	22.4
4 or more	13	6.6	39	19.9	102	52

Table 6. First contact physicians.

First contact physician	Number of patients	Percentage
Pediatrician	134	68.4
Ophthalmology	35	17.9
General Doctor	8	4.1
Emergency Medicine	8	4.1
Otorhinolaryngology	4	2
Family Medicine	2	1
Orthopedic	2	1
School Physician	1	0.5
Gastroenterologist	1	0.5
OB Gynecologist	1	0.5

Table 7. Most common diagnosis prior to brain tumor diagnosis.

	Number of patients	Percentage
Error of refraction	48	24.5
Primary headache	23	11.7
Gastritis/gastroesophageal reflux	20	10.2
Meningitis	12	6.1
Acute gastroenteritis/dehydration	9	4.6
Epilepsy	8	4.1
Urinary tract infection	7	3.6
Stroke	5	2.6
Vertigo	5	2.6
Psychiatric	4	2

Table 8. Predictors of delayed brain tumor diagnosis.

	Beta coefficient (days)	95% CI	p-value
Tumor characteristics
Supratentorial	116.10	24.15, 208.05	0.014
Posterior fossa	-132.80	-259.88, -5.71	0.041
WHO grade IV	-161.52	-260.74, -62.31	0.002
Presenting symptoms at onset
Seizure	331.37	124.37, 538.37	0.002
Poor school performance ^†	380.57	102.35, 658.79	0.008
Behavioral changes	500.07	40.77, 959.37	0.033
Secondary amenorrhea ^†	1122.44	189.69, 2055.19	0.021
Vomiting	-112.85	-207.37, -18.34	0.020

† Patients analyzed for these symptoms included only the population at risk. For poor school performance, patients aged 4 years and above (n = 175) were included, based on average age of school entry at 4 years old. For secondary amenorrhea, only females 13 years and above (n = 36) were included, based on average age of menarche for Filipino female of 13 years old.

Figure 2. Factors associated with delayed diagnosis in pediatric brain tumors among Filipino children admitted at the Philippine General Hospital.

mo: Month.