Sir, we have read with great interest the article by Dave,1 where the author warns about diagnostic delay in oral cancer and makes patients (patient delay), healthcare professionals (doctor delay) and the healthcare system (system delay) responsible for it. The paper also highlights the importance of reducing delayed diagnosis in order to ensure cancer treatment at an early stage. However, when the question 'Why is reducing delayed diagnosis important?' arises, the only answer in the manuscript is that 'the most important prognostic factor in oral cancer is the stage of the tumour at the time of diagnosis', without considering that it has been proved that diagnostic delay is broadly associated with more advanced stage oral cancer (pooled RR: 1.47; 95% CI: 1.09-1.99), particularly when the delay is longer than one month (pooled RR: 1.69; 95% CI: 1.26-2.77).2 Moreover, the estimation of the relative risk of mortality for head and neck carcinomas related to any diagnostic delay (either patient or professional delay) is 1.34 (95% CI: 1.12-1.61), and specifically referral delay is associated with a three-fold increase in mortality.3

Conversely, several research groups have studied the concept of delay in diagnosis of oral cancer but using heterogeneous criteria such as different types of data collected (eg continuous variables versus categorical), or diverse sources of information on patient delay (standard questionnaires, interviews, hospital records, etc) that may – along with variations in tumour biology - explain the absence of a consistent relationship between diagnosis delay and stage at diagnosis in the literature. Despite these shortcomings, diagnostic delay has recently been related to a poorer survival rate in head and neck carcinomas.3

However, The Aarhus Statement has been proposed to improve the design and reporting of studies on early cancer diagnosis.4 This guideline recommends the substitution of the term 'delay' (eg 'patient delay') for 'intervals' or 'time intervals'. The aforementioned statement also suggests key time points (dates of first symptom; first presentation, referral and diagnosis) and time intervals.

Particularly relevant for GDPs are the date of first presentation and the date of referral. This time period could be shortened, as Dave accurately suggests, by using training as part of CPD for all members of the dental team, and a variety of additional approaches.