The impact of delayed diagnosis of lung cancer on the stage at the time of operation

Incidental pulmonary nodules may lead to a high proportion of early-stage lung cancer: but it requires more than a high CT volume to achieve this

Background

The management of pulmonary nodules plays a critical role in early detection of lung cancer. Computed tomography (CT) has led to a stage-shift towards early-stage lung cancer, but regional differences in survival rates have been reported in Denmark. This study aimed to evaluate whether variations in nodule management among Danish health regions contributed to these differences.

Material and Methods

The Danish Health Data Authority and Danish Lung Cancer Registry provided data on CT usage and lung cancer stage distribution, respectively. Auditing of lung cancer stage IA patient referrals and nodule management of stage IV lung cancer patients was conducted in seven Danish lung cancer investigation centers, covering four of the five Danish health regions. CT scans were performed up to 2 years before the patients' diagnosis from 2019 to 2021.

Results

CT usage has increased steadily in Denmark over the past decade, with a simultaneous increase in the proportion of early-stage lung cancers, particularly stage IA. However, one Danish health region, Region Zealand, exhibited lower rates of early-stage lung cancer and overall survival despite a CT usage roughly similar to that of the other health regions. The audit did not find significant differences in pulmonary nodule management or a higher number of missed nodules by radiologists in this region compared to others.

Conclusion

This study suggests that a high CT scan volume alone is not sufficient for the early detection of lung cancer. Factors beyond hospital management practices, such as patient-related delays in socioeconomically disadvantaged areas, may contribute to regional differences in survival rates. This has implications for future strategies for reducing these differences.

Clinical and chest radiographic features of missed lung cancer and their association with patient outcomes

PURPOSE

To examine clinical and chest radiographic features of missed lung cancer (MLC) and explore their association with patient outcomes.

METHODS

We retrospectively reviewed chest radiographs obtained at least six months before lung cancer (LC) diagnosis in 95 patients to identify the first positive chest radiograph showing MLC. We assessed chest radiographic features of MLC and their association with patient outcomes.

RESULTS

Seventy-five (78.9%) patients (39 men, 36 women; mean age, 64.5 ± 10.5 years) had MLC. The median diagnostic delay was 31.3 months (6.6-128.0 months). The median MLC size was 16 mm (5-57 mm), and 54.7%, 68.0%, and 74.7% of MLC were in the left lung, the middle/lower zones, and the outer two-thirds of the lung, respectively. MLC exhibited a round/oval shape, partly/poorly defined margin, irregular/spiculated border, a density less than the aortic knob, and anatomical superimposition in 57.3%, 77.3%, 61.3%, 85.3%, and 88.0% of cases, respectively. Thirty-five (46.7%) patients had stage III + IV LC at diagnosis. Thirty-one (41.3%) patients died. MLC in the inner one-third of the lung, exhibiting a density equal to/greater than the aortic knob, or superimposed by midline structures was significantly associated with stage III + IV LC at diagnosis. The 3-year all-cause mortality significantly increased when MLC was in the upper zone, superimposed by pulmonary vessels, superimposed by pulmonary vessels plus ribs, or superimposed by pulmonary vessels plus in the inner one-third of the lung.

CONCLUSION

MLC with some radiographic features pertaining to their location, density, and superimposed structures was found to portend a worse outcome.

Timeliness of Lung Cancer Care From the Point of Suspicious Image at an Urban Safety Net Hospital

BACKGROUND

Timeliness of care is an important metric for lung cancer patients, and care delays in the safety-net setting have been described. Timeliness from the point of the suspicious image is not well-studied. Herein, we evaluate time intervals in the workup of lung cancer at an urban, safety net hospital and assess for disparities by demographic and clinical factors.

PATIENTS AND METHODS

We performed a retrospective analysis of lung cancer patients receiving some portion of their care at Boston Medical Center between 2015 and 2020. A total of 687 patients were included in the final analysis. Median times from suspicious image to first treatment (SIT), suspicious image to diagnosis (SID), and diagnosis to treatment (DT) were calculated. Nonparametric tests were applied to assess for intergroup differences in time intervals.

RESULTS

SIT, SID, and DT for the entire cohort was 78, 34, and 32 days, respectively. SIT intervals were 87 days for females and 72 days for males (p < .01). SIT intervals were 106, 110, 81, and 41 days for stages I, II, III, and IV, respectively (p < .01). SID intervals differed between black (40.5) and Hispanic (45) patients compared to white (28) and Asian (23) patients (p < .05).

CONCLUSION

Advanced stage at presentation and male gender were associated with more timely treatment from the point of suspicious imaging while white and Asian were associated with more timely lung cancer diagnosis. Future analyses should seek to elucidate drivers of timeliness differences and assess for the impact of timeliness disparities on patient outcomes in the safety net setting.

Olfactometric diagnosis of lung cancer by canine scent - A double-blinded study

BACKGROUND

Lung cancer is one of the most often diagnosed tumours in the world with the highest mortality. A major problem and reason for the high mortality from lung cancer is its diagnosis in the late stages. The main goal of preventing lung cancer deaths is early detection in the early stages and accurate diagnosis, which must be followed by targeted treatment. Nevertheless, even top diagnostic techniques do not have the same accuracy and sensitivity as a dog's sense of smell.

METHODS

The study aims to present the results of olfactometric detection of lung cancer using the smell of dogs in unblinded, single-blinded and double-blinded studies. 115 serum samples or breath from patients with lung cancer and 101 samples from healthy people were used for the training. The group consisted of women and men of Indo-European origin, mostly from the Moravian-Silesian region in Czech Republic. Two dogs were selected for the study.

RESULTS

In the case of tumor detection in the form of unblinded tests, Bugs had a sensitivity of 91% and a specificity of 92%. Boolomo had a sensitivity of 89% and a specificity of 81%. For single-blinded tests, Bugs had a sensitivity of 71%. The sensitivity of Boolomo was set at 90%. After meeting the sensitivity limit of 70%, dogs were included in the double-blinded studies. The highest accuracy was set at 68% for Bugs, 83% for Boolomo.

CONCLUSION

When a tumour is diagnosed in the late stages, it is a great burden on both the health and economic systems of the state. Unfortunately, there is still no suitable screening test to detect the tumour at an early stage, so any other method of detection seems desirable. Trained dogs are used in many fields, why not also in medicine and the diagnosis of tumours?

Delays in Diagnosis and Treatment in Patients Underwent Endobronchial Ultrasound-Transbronchial Needle Aspiration (EBUS-TBNA)

OBJECTIVES

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has been recognized as the first method of choice in the diagnosis of mediastinal and hilar lesions. Although the procedure is commonly used, there is no study assessing its contribution to the duration required for diagnosis and treatment. In this study, we aimed to determine the extent of diagnosis and treatment delays when using the EBUS-TBNA procedure and to address the possible factors contributing to these delays.

MATERIALS AND METHODS

The demographic data, pathological diagnosis, need for additional procedures, symptoms, presenting complaints, and the time until the beginning of treatment were recorded retrospectively in all patients who had undergone EBUS-TBNA.

RESULTS

A total of 134 patients (mean age 60.7 ± 12 years, M/F: 78/56) were included. Delay of the patients was found in 60.4% (n = 81), delayed referral in 35.8% (n = 48), diagnosis delays in 84.3% (n = 113), treatment delays in 38.8% (n = 52), and total delay in 73.1% (n = 98) of the patients. A statistically significant association was found between referral delay and total delay with age groups (p=0.006) and between patient delay and the presence of symptoms (p=0.027). EBUS-TBNA was found to have the lowest effect among all delay parameters (β: 0.104, p < 0.001) in the regression analysis. When diagnosis times' subgroups were compared, EBUS-TBNA was found to have the least effect (correlation coefficient: 0.134, p=0.004).

CONCLUSION

We found that approximately ¾ of the patients had a delay and this is not acceptable in real terms. Considering that the patient burden is increasing day by day, it is necessary to make a radical change in health care or a change in strategy in order to prevent delays. EBUS-TBNA, which is in the diagnosis delay subgroup, is less invasive and accelerates the process.

Primary care system factors and clinical decision-making in patients that could have lung cancer: A vignette study in five balkan region countries

Introduction

Lung cancer is the leading cause of cancer death, with wide variations in national survival rates. This study compares primary care system factors and primary care practitioners’ (PCPs’) clinical decision-making for a vignette of a patient that could have lung cancer in five Balkan region countries (Slovenia, Croatia, Bulgaria, Greece, Romania).

Methods

PCPs participated in an online questionnaire that asked for demographic data, practice characteristics, and information on health system factors. Participants were also asked to make clinical decisions in a vignette of a patient with possible lung cancer.

Results

The survey was completed by 475 PCPs. There were significant national differences in PCPs’ direct access to investigations, particularly to advanced imaging. PCPs from Bulgaria, Greece, and Romania were more likely to organise relevant investigations. The highest specialist referral rates were in Bulgaria and Romania. PCPs in Bulgaria were less likely to have access to clinical guidelines, and PCPs from Slovenia and Croatia were more likely to have access to a cancer fast-track specialist appointment system. The PCPs’ country had a significant effect on their likelihood of investigating or referring the patient.

Conclusions

There are large differences between Balkan region countries in PCPs’ levels of direct access to investigations. When faced with a vignette of a patient with the possibility of having lung cancer, their investigation and referral rates vary considerably. To reduce diagnostic delay in lung cancer, direct PCP access to advanced imaging, availability of relevant clinical guidelines, and fast-track referral systems are needed.

Evaluating the delay prior to primary care presentation in patients with lung cancer: a cohort study

Background

Little is known about 'within-patient delay', which is the time from first symptom of lung cancer to contacting primary care.

Aim

Primary outcomes were length of within-patient delay and the proportion of total delay it represents. Secondary outcomes were factors causing delay and survival.

Design & setting

A cohort study of newly diagnosed patients with lung cancer at two hospitals in Norfolk.

Method

Patients completed questionnaires regarding onset of symptoms, whether they had delayed, and their reasons. GPs completed correlating questionnaires. Pathway times and other data were extracted from cancer registry and hospital records, and outcomes obtained prospectively. Factors causing delay were compared using ratios of geometric means.

Results

In 379 patients, mean within-patient delay and pre-secondary care delay were 188.6 days and 241 days (61.4% and 78.5% of total delay, respectively). It was found that 38.8% of patients felt they had delayed. Patient-related causes of delay were denial (ratio of means [ROM] = 4.36; P = 0.002, 95% confidence interval [CI] = 1.71 to 11.1); anxiety (ROM = 3.36; P = 0.026; 95% CI = 1.16 to 9.76); non-recognition of symptoms (ROM = 2.80; P = 0.004; 95% CI = 1.41 to 5.59); and smoking (ROM = 1.76; P = 0.021; 95% CI = 1.09 to 2.86), respectively. These symptoms were associated with delay: finger swelling or discomfort (ROM = 2.72; P = 0.009, 95% CI = 1.29 to 5.74); cough (ROM = 2.53; P<0.001; 95% CI = 1.52 to 4.19); weight loss (ROM = 2.41; P<0.001; 95% CI = 1.49 to 3.88); weakness (ROM = 2.35; P = 0.001; 95% CI = 1.45 to 3.83); dyspnoea (ROM = 2.30; P = 0.001; 95% CI = 1.40 to 3.80); voice change (ROM = 1.90; P = 0.010; 95% CI = 1.17 to 3.10); and sputum (ROM = 1.66; P = 0.039; 95% CI = 1.03 to 2.67), respectively, also having more than five symptoms (compared with 1–3) (ROM = 3.69; P<0.001; 95% CI = 2.05 to 6.64). No overall relation between within-patient delay and survival was seen.

Conclusion

Using smoking registers, awareness literature, and self-care manuals, primary care staff could liaise with people who have ever smoked regarding their symptoms to ensure early referral to secondary care.

Delay to surgical treatment in lung cancer patients and its impact on survival in a video-assisted thoracoscopic lobectomy cohort

Patient pathways from first suspicious imaging until final surgical treatment vary and in some instances cause considerable delay. This study aims to investigate the impact of this delay on survival of lung cancer patients. The institutional database was queried to identify patients with primary lung cancer who were treated with primary surgery. Time intervals were defined as date of first suspicious medical images until date of surgical treatment. All patients received PET-CT staging and tissue confirmation prior to treatment planning in a multidisciplinary tumor board. Patients with unknown date of first contact, follow-up CT-scans of pulmonary nodules, or neoadjuvant therapy were excluded. In total, 287 patients treated between 2009 and 2017 were included for further analysis. Median time between first suspicious medical imaging and surgical therapy was 62 (range 23–120) days and did not differ between male and female patients. Patients were then classified into two groups according to the duration of the medical work-up: group A up to 60 days, and group B from 61 to 120 days. Clinical T and N stages were comparable between the groups. There was no difference in overall survival between the two groups. In the subgroup of cT2 tumors (87 patients), there was a significant survival benefit for patients in group A (p = 0.043), while nodal stages, stage migration, lymphatic vessel invasion, grading and other potentially survival-influencing clinical parameters were comparable between the groups. Delay between diagnosis and treatment of lung cancer may result in dismal outcome. Efforts need to focus on improving and streamlining patient pathways to shorten the delay until surgical treatment to a minimum. Process improvement might be achieved by stringent interdisciplinary work-up and a patient-centered approach.

Cancer diagnostic tools to aid decision-making in primary care: mixed-methods systematic reviews and cost-effectiveness analysis

BACKGROUND

Tools based on diagnostic prediction models are available to help general practitioners diagnose cancer. It is unclear whether or not tools expedite diagnosis or affect patient quality of life and/or survival.

OBJECTIVES

The objectives were to evaluate the evidence on the validation, clinical effectiveness, cost-effectiveness, and availability and use of cancer diagnostic tools in primary care.

METHODS

Two systematic reviews were conducted to examine the clinical effectiveness (review 1) and the development, validation and accuracy (review 2) of diagnostic prediction models for aiding general practitioners in cancer diagnosis. Bibliographic searches were conducted on MEDLINE, MEDLINE In-Process, EMBASE, Cochrane Library and Web of Science) in May 2017, with updated searches conducted in November 2018. A decision-analytic model explored the tools' clinical effectiveness and cost-effectiveness in colorectal cancer. The model compared patient outcomes and costs between strategies that included the use of the tools and those that did not, using the NHS perspective. We surveyed 4600 general practitioners in randomly selected UK practices to determine the proportions of general practices and general practitioners with access to, and using, cancer decision support tools. Association between access to these tools and practice-level cancer diagnostic indicators was explored.

RESULTS

Systematic review 1 - five studies, of different design and quality, reporting on three diagnostic tools, were included. We found no evidence that using the tools was associated with better outcomes. Systematic review 2 - 43 studies were included, reporting on prediction models, in various stages of development, for 14 cancer sites (including multiple cancers). Most studies relate to QCancer® (ClinRisk Ltd, Leeds, UK) and risk assessment tools.

DECISION MODEL

In the absence of studies reporting their clinical outcomes, QCancer and risk assessment tools were evaluated against faecal immunochemical testing. A linked data approach was used, which translates diagnostic accuracy into time to diagnosis and treatment, and stage at diagnosis. Given the current lack of evidence, the model showed that the cost-effectiveness of diagnostic tools in colorectal cancer relies on demonstrating patient survival benefits. Sensitivity of faecal immunochemical testing and specificity of QCancer and risk assessment tools in a low-risk population were the key uncertain parameters.

SURVEY

Practitioner- and practice-level response rates were 10.3% (476/4600) and 23.3% (227/975), respectively. Cancer decision support tools were available in 83 out of 227 practices (36.6%, 95% confidence interval 30.3% to 43.1%), and were likely to be used in 38 out of 227 practices (16.7%, 95% confidence interval 12.1% to 22.2%). The mean 2-week-wait referral rate did not differ between practices that do and practices that do not have access to QCancer or risk assessment tools (mean difference of 1.8 referrals per 100,000 referrals, 95% confidence interval -6.7 to 10.3 referrals per 100,000 referrals).

LIMITATIONS

There is little good-quality evidence on the clinical effectiveness and cost-effectiveness of diagnostic tools. Many diagnostic prediction models are limited by a lack of external validation. There are limited data on current UK practice and clinical outcomes of diagnostic strategies, and there is no evidence on the quality-of-life outcomes of diagnostic results. The survey was limited by low response rates.

CONCLUSION

The evidence base on the tools is limited. Research on how general practitioners interact with the tools may help to identify barriers to implementation and uptake, and the potential for clinical effectiveness.

FUTURE WORK

Continued model validation is recommended, especially for risk assessment tools. Assessment of the tools' impact on time to diagnosis and treatment, stage at diagnosis, and health outcomes is also recommended, as is further work to understand how tools are used in general practitioner consultations.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42017068373 and CRD42017068375.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology programme and will be published in full in Health Technology Assessment; Vol. 24, No. 66. See the NIHR Journals Library website for further project information.

Awareness is the first step: What Ghanaian community pharmacists know about cancer

OBJECTIVES

The goal of this study was to access the knowledge of a representative sample of community pharmacists in Ghana on general cancer, risk factors, signs and symptom and most common cancer counseling points known to community pharmacists.

METHODS

A structured online questionnaire was administered to 435 registered community pharmacists in the sixteen regions of Ghana.Key findings: Mean score for knowledge of cancer among community pharmacists was 6.8 ± 1.61 points out of a maximum score of 15 points, categorizing the overall knowledge as inadequate. The overall assessment of pharmacists' knowledge revealed that 74.6% of the participants had inadequate level of knowledge on cancer. Mean score for knowledge of cancer signs and symptoms among community pharmacists was 3.55 ± 1.85 out of a maximum score of 7 points, categorizing the overall knowledge as inadequate. The overall evaluation indicated that 79.03% of pharmacists had inadequate knowledge of signs and symptoms cancer. Mean score for knowledge of risk factors of cancer among community pharmacists was 5.25 ± 1.15 out of a maximum score of 12 points, categorizing the overall knowledge as inadequate. The overall assessment of the knowledge score indicates that 70.34% of pharmacists had inadequate knowledge about causes and risk factors of cancer. Almost all participating pharmacists (96.5%) recommended counselling point was avoidance of smoking as a cancer preventive measure. An inverse significant correlation was found between age and knowledge scores of signs and symptoms of cancer (r = -0.077, P = 0.038). There was a statistically significant relationship between pharmacists' level of knowledge on cancer (whether adequate or inadequate) and the cancer items.

CONCLUSIONS

Knowledge of cancer, its signs and symptoms and its risk factors were inadequate among community pharmacists in Ghana. Efforts should be made to improve knowledge of community pharmacists on cancer through continuous education. Also, undergraduate pharmacy training in oncology should encourage to close knowledge gap of community pharmacists on cancer.

The progression of non-small cell lung cancer from diagnosis to surgery

OBJECTIVES

The IASLC 8th TNM Staging 8th differentiates between a greater number of T-stages. Resection remains the mainstay of curative treatment with often significant waiting times. This study aims to quantify the T-stage progression and growth of non-small cell lung cancers (NSCLCs) between radiological diagnosis and resection, and its impact on disease recurrence and survival.

MATERIALS AND METHODS

A retrospective analysis of NSCLC resections (289) in a high-volume centre between July 01, 2015 and June 30, 2016. Baseline demographics, time from diagnostic CT to surgery, tumour size (cm) and T-stage from diagnostic CT, PET-CT and post-operative histopathology reports were recorded. The primary outcome was increase in T-stage from diagnostic CT to resection. Kaplan-Meier and cox proportional hazard analyses were used to determine recurrence-free survival and survival.

RESULTS

Median increase in tumour size between diagnosis and resection was 0.3 cm (p < 0.0001). Median percentage increase in size was 13%. T-stage increased in 133 (46.0%) patients. N stage increased in 51 patients (17.7%), 32 (11.1%) to N2 disease. Mean survival in those upstaged was 43.5 (39.9-47.1) months versus 53.4 (50.0-56.8) months in patients not upstaged (p = 0.025). Mean recurrence-free survival in those upstaged was 39.1 (35.2-43.0) months versus 47.7 (43.9-51.4) months in patients not upstaged (p = 0.117). Upstaging was independently associated with inferior survival (HR 1.674, p = 0.006) and inferior recurrence-free survival (HR 1.423, p = 0.038).

CONCLUSIONS

A significant number of patients are upstaged between diagnostic and resection resulting in reduced survival and recurrence-free survival. A change in management pathways are required to improve outcomes in NSCLC.

The impact of concordance with a lung cancer diagnosis pathway guideline on treatment access in patients with stage IV lung cancer

Background

Timely access to treatment of lung cancer is dependent on efficient and appropriate patient assessment and early referral for diagnostic workup. This study assesses the impact of Cancer Care Ontario (CCO) Lung Cancer Diagnostic Pathway Guideline (LCDPG) concordance on access to treatment of stage IV lung cancer patients referred to the Diagnostic Assessment Program (DAP) at a Canadian tertiary cancer centre.

Methods

This retrospective cohort study includes patients diagnosed with clinical stage IV lung cancer referred to the DAP at a Canadian tertiary cancer centre between November 1, 2015 and May 31, 2017. Referral concordance was determined based on CCO LCDPG. The primary outcome; time to treatment from initial healthcare presentation; was compared between the concordant and discordant referrals.

Results

Two hundred patients were referred for clinical stage IV lung cancer during the study period. Of these referrals, 151 (75.5%) were assessed and referred in concordance with LCDPG. Guideline concordant referrals were associated with reduced time to treatment from first healthcare presentation compared with guideline discordant referrals (55.3 vs. 108.8 days, P<0.001). Time to diagnostic procedure (32.2 vs. 86.7 days, P<0.001) and decision to treat (38.5 vs. 93.8 days, P<0.001) were also reduced with guideline concordance. The most common reason for discordant assessment and referral was delayed or inadequate investigation of symptoms in a high risk patient (32.7% of discordant referrals).

Conclusions

Guideline concordant assessment and referral of stage IV lung cancer patients results in reduced time to diagnosis and treatment. Future research and education should focus on improving factors that delay DAP referral.

Effect of time interval from diagnosis to treatment for non-small cell lung cancer on survival: a national cohort study in Taiwan

OBJECTIVES

This study aimed to determine if treatment delay after non-small cell lung cancer (NSCLC) diagnosis impacts patient survival rate.

STUDY DESIGN

This study is a natural experiment in Taiwan. A retrospective cohort investigation was conducted from 2004 to 2010, which included 42 962 patients with newly diagnosed NSCLC.

METHODS

We identified 42 962 patients with newly diagnosed NSCLC in the Taiwan Cancer Registry from 2004 to 2010. We calculated the time interval between diagnosis and treatment initiation. All patients were followed from the index date to death or the end of 2012. Cox proportional hazard models were used to examine the relationship between mortality and time interval.

RESULTS

We included 42 962 patients (15 799 men and 27 163 women) with newly diagnosed NSCLC. The mortality rate exhibited a significantly positive correlation to time interval from cancer diagnosis to treatment initiation. The adjusted HRs ranged from 1.04 to 1.08 in all subgroups time interval more than 7 days compared with the counterpart subgroup of the interval from cancer diagnosis to treatment ≤7 days. The trend was also noted regardless of the patients with lung cancer in stage I, stage II and stage III.

CONCLUSIONS

There is a major association between time to treat and mortality of patients with NSCLC, especially in stages I and II. We suggest that efforts should be made to minimise the interval from diagnosis to treatment while further study is ongoing to determine causation.

Treatment Delays in Primarily Resected Oropharyngeal Squamous Cell Carcinoma: National Benchmarks and Survival Associations

OBJECTIVE

To characterize treatment delays in surgically treated oropharyngeal cancer, identify factors associated with delays, and associate delays with survival.

STUDY DESIGN

Retrospective cross-sectional analysis.

SETTING

Commission on Cancer-accredited institutions.

SUBJECTS AND METHODS

We identified patients in the National Cancer Database with surgically treated oropharyngeal cancer. We characterized the durations of diagnosis-to-treatment initiation, surgery-to-radiation treatment, radiation treatment duration, total treatment package, and diagnosis-to-treatment end intervals as medians. We associated delays with patient, tumor, and treatment factors via multivariable logistic regression analysis and with overall survival by Cox proportional hazards regression.

RESULTS

In total, 3708 patients met inclusion criteria. Median durations of diagnosis-to-treatment initiation, surgery-to-radiation treatment, radiation treatment duration, total treatment package, and diagnosis-to-treatment end intervals were 27, 42, 47, 90, and 106 days, respectively. Medicaid and human papillomavirus (HPV) negativity were associated with delays. Delayed total treatment package and diagnosis-to-treatment end intervals were associated with decreased survival (hazard ratio [HR] = 1.81 [1.29-2.54], P = .001 and HR = 1.97 [1.39-2.78], P < .001, respectively); this was maintained following HPV stratification. Delays in the surgery-to-radiation treatment interval were associated with decreased overall survival in HPV-negative but not HPV-positive patients (HR = 2.05 [1.19-3.52], P = .010 and HR = 1.15 [0.74-1.80], P = .535, respectively). Diagnosis-to-treatment initiation and radiation treatment duration were not associated with overall survival in the overall cohort (HR = 1.21 [0.86-1.72], P = .280 and HR = 1.40 [0.99-1.99], P = .061, respectively); however, following stratification, delayed radiation treatment duration approached significance in HPV-negative but not HPV-positive patients (HR = 1.60 [0.96-2.68], P = .072 and HR = 1.35 [0.84-2.18], P = .220).

CONCLUSION

Treatment durations identified here can serve as national benchmarks and for institutions to compare quality to their peers. Distinct benchmarks should be applied to HPV-negative and HPV-positive patients.

The survival impact of surgical waiting time in patients with resectable pancreatic head cancer

Backgrounds/Aims

After centralization policy, clinical outcomes have been improved in patients underwent pancreaticoduodenectomy for pancreatic cancer. However, centralization could exacerbate the prolongation of surgical waiting time. This study aims to investigate whether the shorter waiting time correlates with the better survival and to identify the major confounders that influence the association between those.

Methods

In this retrospective cohort study, a total 554 patients with pathologically confirmed pancreatic ductal adenocarcinoma were assessed the eligibility from 2014 through 2015. Patients with neoadjuvant chemotherapy, body-tail resection, total pancreatectomy and combined adjacent organ resection were excluded. All patients were divided into two groups by median waiting time, 21 days, defined as the date difference between initial imaging diagnosis and operation.

Results

Median overall survival did not differ between long and short waiting group (30.4 vs 24.8 months, p=0.35; HR=0.84, 95% CI=0.58-1.21). The proportion of cancer stage shifting, the difference between clinical and pathologic staging, did not differ depending on waiting time group (p=0.811 and 0.255, each of reviewers). Short waiting time was highly correlated with high initial clinical stage (Spearman correlation coefficients -0.201 (p=0.006) and -0.100 (p=0.175), each of reviewers).

Conclusions

Initial clinical stage had confounding effect on the association between waiting time and overall survival. Therefore, in evaluating centralization policy at the national level, evidence for maximum acceptable waiting time should be investigated in the near future with considering that surgical waiting time could be affected by initial clinical stage.

Hypopharyngeal Cancer Treatment Delays: Benchmarks and Survival Association

Objective

To characterize treatment delays in hypopharyngeal cancer, identify factors associated with delays, and associate delays with overall survival.

Study Design

Retrospective cohort.

Setting

Commission on Cancer hospitals nationwide.

Subjects and Methods

We included patients in the National Cancer Database who were treated for hypopharyngeal cancer with primary radiation, concurrent chemoradiation, or induction chemotherapy and radiation. We identified median durations of diagnosis to treatment initiation (DTI), radiation treatment duration (RTD), and diagnosis to treatment end (DTE). We associated delays with patient, tumor, and treatment factors and overall survival via multivariable logistic and Cox proportional hazards regression, respectively.

Results

A total of 3850 patients treated with primary radiation or concurrent chemoradiation were included. Median durations of DTI, RTD, and DTE were 37, 52, and 92 days, respectively. Nonwhite race was associated with delays in DTI (odds ratio [OR] = 0.64; 95% CI, 0.51-0.80; P < .001) and DTE (OR = 0.60; 95% CI, 0.49-0.75; P < .001). Medicaid insurance was associated with delays in DTI (OR = 1.43; 95% CI, 1.07-1.90; P = .015), RTD (OR = 1.39; 95% CI, 1.06-1.83; P = .018), and DTE (OR = 1.48; 95% CI, 1.12-1.97; P = .007). Delays in RTD (hazard ratio [HR] = 1.24; 95% CI, 1.11-1.37; P < .001), not DTI (HR = 0.92; 95% CI, 0.82-1.03; P = .150) or DTE (HR = 1.01; 95% CI, 0.90-1.15; P = .825), were associated with impaired overall survival. We identified 922 patients who received induction chemotherapy. Delays in DTI, RTD, and DTE were not associated with overall survival in this cohort (HR = 1.10; 95% CI, 0.87-1.39; P = 0.435; HR = 1.05; 95% CI, 0.83-1.32; P = 0.686; HR = 1.11; 95% CI, 0.88-1.41; P = 0.377, respectively).

Conclusions

The median durations identified can serve as national benchmarks. Delays during radiation are associated with impaired overall survival among patients treated with primary radiation or chemoradiation but not patients treated with induction chemotherapy.

Does the surgical waiting list affect pathological and survival outcome in resectable pancreatic ductal adenocarcinoma?

BACKGROUND

High-volume centers have to deal with long surgical waiting-lists leading to a potential delay in treatment. This study assessed whether a longer time from diagnosis to surgery worsened pathological and survival outcomes in resectable pancreatic ductal adenocarcinoma (PDAC).

METHODS

A retrospective analysis of patients treated for resectable PDAC. Difference in size between preoperative CT-scan and specimen, pathological features, the rate of vascular and R1 resections as well as recurrence and survival were analyzed depending on the waiting time using a 30-day cut-off.

RESULTS

Waiting more than 30 days for surgery was associated with an increase in tumor size on specimen when compared with CT-scan (+3 vs. +1 mm, p = 0.04). T and N status, rate of vascular resection, grading, perineural and lymphovascular infiltration, and R1 rates did not differ between groups, as well as tumor recurrence (48.8% vs. 48.9%, p = 0.5) and survival (31 vs. 29 months, p = 0.7). For PDAC < 20 mm, waiting less than 30 days improved overall survival (p = 0.02).

CONCLUSION

The duration of the surgical waiting-list did not affect pathological features and survival. Delayed surgery was associated with increased cancer size on the specimen. However, surgery should not be delayed for PDACs < 20 mm as this may negatively affect the prognosis.

Delays in the Diagnosis and Treatment of Non-Small-Cell Lung Cancer

Aims

To investigate patterns of delays among patients with non-small-cell lung cancer and to identify reasons for the delays.

Methods

This prospective study included 101 patients with non-small-cell lung carcinoma. Clinical files of the patients were analyzed and a questionnaire was created to obtain data. Several time intervals and delays were determined for each patient. The reasons for the delays were also evaluated.

Results

The mean time was 59.9 days for the application interval, 40.3 days for the referral interval, 16.4 days for the diagnostic interval, and 24.7 days for the treatment interval. The application interval was longer than 30 days (patient's delay) in 48 patients (48.5%). There was a doctor delay in 54 (53.5%) patients, a referral delay in 47 (46.5%) patients, a diagnostic delay in 37 (36.6%) patients, and a treatment delay in 57 (56.4%) patients. The mean total time was 119.6 days. Sixty-two patients (62.6%) had a total delay. The most common reason for patient's delay was neglect of symptoms by patients. A low index of suspicion for lung cancer was the most common cause for referral delay. The low performance of diagnostic tests was the frequent reason for diagnostic delay.

Conclusions

Patient's and doctor's delays were a common problem among patients with non-small-cell lung cancer. The rate of doctor's delay was higher than that of patient's delay. Several efforts such as education of the physicians and people about lung cancer should be made to reduce these delays.

Effect of Symptom-To-Treatment Interval on Prognosis in Lung Cancer

Aims and background

To evaluate the relationship between delayed diagnosis and the degree of invasion and survival in lung cancer.

Methods

One hundred and three patients (96 men) with lung cancer were included. Stages in the diagnosis of lung cancer were classified as follows: symptom-to-doctor interval, i.e., the interval from the first symptoms related to the presence of lung cancer to the first consultation with a medical professional; doctor-to-diagnosis interval, i.e., the interval between the first medical visit and confirmation of the diagnosis; and diagnosis-to-treatment interval, i.e., the interval between diagnosis and complete TNM staging and treatment. The symptom-to-treatment interval (STI) was the sum of the 3 intervals. The degree of invasion was determined by the TNM classification.

Results

The patients were followed up for a mean period (± SD) of 7.4 ± 8.7 months. Seventy-six (74%) patients were diagnosed with non-small cell lung cancer (NSCLC) and 27 patients (26%) with small cell lung cancer (SCLC). The mean length of STI was 120 ± 101 days (median, 90). The mean length of the symptom-to-doctor interval was 63 ± 62 days (median, 45), while the doctor-to-diagnosis and diagnosis-to-treatment intervals were 41 ± 82 days (median, 10) and 16 ± 12 days (median, 12), respectively. When the STIs of the patients were correlated with tumor stage, tumor invasion, lymph node involvement and metastasis, no significant differences were found. Patients with an STI longer than 60 days had a significantly longer survival. Regarding the type of lung cancer and STI, the median survival was shorter in patients with an STI of less than 60 days both in NSCLC and SCLC, although this was not statistically significant in SCLC.

Conclusions

The shorter the diagnostic interval, the shorter was the median survival in our study. The reason for the apparent discrepancy between poor prognosis of lung cancer patients in spite of early diagnosis might be much faster progression of the disease itself.

Factors Affecting the Interval from Diagnosis to Treatment in Patients with Lung Cancer

Aims and Background

We aimed to investigate the factors affecting the interval from the beginning of the symptoms until diagnosis and treatment in patients with lung cancer.

Methods

Records of 119 lung cancer patients diagnosed in our pulmonary diseases clinic between 2004 and 2006 were evaluated retrospectively. Demographic data, histopathological tumor type, TNM stage, ECOG performance status, presence of endobronchial lesions, and radiological localization of the tumor were determined. Intervals from the first symptom to contacting a doctor, to diagnosis and to treatment were calculated. The interval from first admission to a clinic and referral to a chest physician was also calculated.

Results

Of 119 patients, 74% were diagnosed as non-small cell and 26% were as small cell lung cancer. Forty-eight percent of the patients were at stage 3B and 36% were at stage 4. ECOG performance status was 0 in 6%, 1 in 52%, 2 in 36%, 3 in 3%, and 4 in 2%. Endobronchial lesions were observed in 50% of the patients, and the lesions had a central radiological localization in 59%. Fifty-four percent of the patients presented to a chest physician first. Patients who first presented to an internal medicine clinic were referred to our pulmonary disease clinic significantly later than those who presented to other clinics (P = 0.005). The median period from the beginning of the symptoms until contacting a doctor was 35 days (range, 1-387), until diagnosis was 49 days (range, 12-396), and until beginning the treatment was 57 (range, 9-397) days. The presence of endobronchial lesions, radiological localization, TNM stage and ECOG performance status were not found to be related to the intervals from the first symptom to presentation to a doctor, to diagnosis or to the beginning of the treatment.

Conclusions

Lung cancer patients consult a doctor after a relatively long symptomatic period. Patient delays may be shortened by increasing the awareness of patients about lung cancer symptoms. Diagnostic procedures should be performed more rapidly to shorten doctor delays.

No clinical significance of the time interval between biopsy and robotic-assisted radical prostatectomy for patients with clinically localized prostate cancer on biochemical recurrence: a propensity score matching analysis

Purpose

To investigate the impact of the time interval (TI) between prostate biopsy and robot-assisted radical prostatectomy (RARP) on the risk of biochemical recurrence (BCR).

Methods

We retrospectively reviewed the medical records of 793 consecutive patients who were treated with RARP at our institution. Patients were divided into three groups, according to TI, to compare BCR-free survival (BCRFS) rates: Group 1 (n = 196), TI < 3 months; Group 2 (n = 513), 3 ≤ TI < 6 months; Group 3 (n = 84), TI ≥ 6 months. Eighty-three patients with TI ≥ 6 months were matched with an equal number of patients with TI < 6 months based on propensity scores by using four preoperative factors: prostate-specific antigen (PSA), primary (pGS) and secondary (sGS) Gleason score and positive prostate biopsy.

Results

The 5-year BCRFS rates for TI Groups 1, 2, and 3 were 76%, 80.7% and 82.6% (P = 0.99), respectively. The multivariate analysis revealed that PSA, pGS, sGS and a positive prostate biopsy were independent preoperative risk factors for BCR. The propensity adjusted 5-year BCRFS for patients with TI ≥ 6 months was 84.0%. This was not worse than that of patients with TI < 6 months (71.0%, P = 0.18).

Conclusions

In our cohorts, a delay in the time from biopsy to RARP did not significantly affect recurrence. Therefore, hasty treatment decisions are unnecessary for at least 6 months after diagnosis of early prostate cancer.

Timeliness of Care and Lung Cancer Tumor-Stage Progression: How Long Can We Wait?

BACKGROUND

Timely care of lung cancer is presumed critical, yet clear evidence of stage progression with delays in care is lacking. We investigated the reasons for delays in treatment and the impact these delays have on tumor-stage progression.

METHODS

We queried our retrospective database of 265 veterans who underwent cancer resection from 2005 to 2015. We extracted time intervals between nodule identification, diagnosis, and surgical resection; changes in nodule radiographic size over time; final pathologic staging; and reasons for delays in care. Pearson's correlation and Fisher's exact test were used to compare cancer growth and stage by time to treatment.

RESULTS

Median time from referral to surgical evaluation was 11 days (interquartile range, 8 to 17). Median time from identification to therapeutic resection was 98 days (interquartile range, 66 to 139), and from diagnosis to resection, 53 days (interquartile range, 35 to 77). Sixty-eight patients (26%) were diagnosed at resection; the remainder had preoperative tissue diagnoses. No significant correlation existed between tumor growth and time between nodule identification and resection, or between tumor growth and time between diagnosis and resection. Among 197 patients with preoperative diagnoses, 42% (83) had intervals longer than 60 days between diagnosis and resection. Most common reasons for delay were cardiac clearance, staging, and smoking cessation. Larger nodules had fewer days between identification and resection (p = 0.03).

CONCLUSIONS

Evaluation, staging, and smoking cessation drive resection delays. The lack of association between tumor growth and time to treatment suggests other clinical or biological factors, not time alone, underlie growth risk. Until these factors are identified, delays to diagnosis and treatment should be minimized.

Transfer between hospitals as a predictor of delay in diagnosis and treatment of patients with Non-Small Cell Lung Cancer - a register based cohort-study

Background

Lung cancer is the second most frequent cancer diagnosis in Denmark. Although improved during the last decade, the prognosis of lung cancer is still poor with an overall 5-year survival rate of approximately 12%. Delay in diagnosis and treatment of lung cancer has been suggested as a potential cause of the poor prognosis and as consequence, fast track cancer care pathways were implemented describing maximum acceptable time thresholds from referral to treatment. In Denmark, patients with lung cancer are often transferred between hospitals with diagnostic facilities to hospitals with treatment facilities during the care pathway. We wanted to investigate whether this organizational set-up influenced the time that patients wait for the diagnosis and treatment. Therefore, the objective of this study was to uncover the impact of transfer between hospitals on the delay in the diagnosis and treatment of Non-Small Cell Lung Cancer (NSCLC).

Methods

We performed a historical prospective cohort study using data from the Danish Lung Cancer Registry (DLCR). All patients diagnosed with primary NSCLC from January 1st 2008 to December 31st 2012 were included. Patients with unresolved pathology and incomplete data on the dates of referral, diagnosis and treatment were excluded.

Results

A total of 11 273 patients were included for further analyses. Transfer patients waited longer for treatment after the diagnosis, (Hazard ratio (HR) 0.81 (0.68–0.96)) and in total time from referral to treatment (HR 0.84 (0.77–0.92)), than no-transfer patients. Transfer patients had lower odds of being diagnosed (Odds Ratio (OR) 0.82 (0.74–0.94) and treated (OR 0.66 (0.61–0.72) within the acceptable time thresholds described in the care pathway.

Conclusion

Fast track cancer care pathways were implemented to unify and accelerate the diagnosis and treatment of cancer. We found that the transfer between hospitals during the care pathway might cause delay from diagnosis to treatment as well as in the total time from referral to treatment in patients with Non Small-Cell Lung Cancer. The difference between no-transfer and transfer patients persists after adjusting for known predictors of delay.

The role of oncology nurse navigators in facilitating continuity of care within the diagnostic phase for adult patients with lung cancer

Objective

The objective of this study was to explore the role of oncology nurse navigators (ONN) in facilitating continuity of care for adult lung cancer patients during the diagnostic phase of cancer care.

Design

A phenomenological approach was used and involved semi-structured patient interviews and an oncology nurse navigators' focus group.

Results

Eight individuals participated, including four adult patients with lung cancer and four oncology nurse navigators. Themes regarding the organizational functions of the ONN role in facilitating continuity of care were identified: patient-focused care, needs assessments, shared decision-making, accessibility, and eliminating barriers.

Conclusion

Awareness of the organizational functions of the ONN role could be used to create core areas of practice within nursing training modules to provide consistent and patient-centred continuity of care.

Knowledge of the signs and symptoms and risk factors of lung cancer in Australia: mixed methods study

BACKGROUND

Lung cancer is the leading cause of cancer death in Australia. There is potential that health promotion about the risks and warning signs of lung cancer could be used to reduce delays in symptom presentation when symptoms are first detected. This study investigated knowledge, attitudes and beliefs which might impact help-seeking behaviour and could provide insight into possible public health interventions in New South Wales (NSW).

METHODS

A convergent mixed method study design was used wherein data from 16 qualitative focus groups of residents (40+ years), purposefully recruited and stratified by smoking status, age and geography (metropolitan/regional), were compared with a CATI administered population-wide telephone survey (n = 1,000) using the Cancer Research UK cancer awareness measure (LungCAM). Qualitative findings were analysed thematically using NVIVO. Logistic regression analysis was used to investigate predictors of symptom knowledge in STATA. Findings were integrated using triangulation techniques.

RESULTS

Across focus groups, haemoptysis was the only symptom creating a sense of medical urgency. Life experiences evoked a 'wait and see' attitude to any health deterioration. Perceived risk was low amongst those at risk with current smokers preferring to deny their risk while former smokers were generally unaware of any ongoing risk. The quantitative sample consisted of females (62 %), 40-65 years (53 %), low SES (53 %), former (46 %) and current smokers (14 %). In quantitative findings, haemoptysis and dyspnoea were the most recognised symptoms across the sample population. Age (<65 years), sex (female) and high socio-economic status contributed to a higher recognition of symptoms. Smoking was recognised as a cause of lung cancer, yet ever-smokers were less likely to recognise the risk of lung cancer due to second-hand smoke (OR 0.7 95 % CI 0.5-0.9).

CONCLUSION

While there was some recognition of risk factors and symptoms indicative of lung cancer, there was disparity across the sample population. The qualitative findings also suggest that knowledge may not lead to earlier presentation; a lack of urgency about symptoms considered trivial, and smoking-related barriers such as stigma may also contribute to time delays in presentation. Public health interventions may be required to increase awareness of risk and emphasise the importance of seeking medical attention for ongoing symptoms.

Time-to-Surgery and Survival Outcomes in Resectable Colorectal Liver Metastases: A Multi-Institutional Evaluation

BACKGROUND

Resection of colorectal liver metastases (CRLM) is associated with improved survival; however, the impact of time to resection on survival is unknown. The current multi-institutional study sought to evaluate the influence of time from diagnosis (Dx) to resection (Rx) on survival outcomes among patients with resectable, metachronous CRLM and to compare practice patterns across hospitals.

STUDY DESIGN

Medical records of patients with ≤4 metachronous CRLM treated with surgery were reviewed and analyzed retrospectively. Time from Dx to Rx was analyzed as a continuous variable and also dichotomized into 2 groups (group 1: Dx to Rx <3 months and group 2: Dx to Rx ≥3 months) for additional analysis. Survival time distributions after resection were estimated using the Kaplan-Meier method. Between-group univariate comparisons were based on the log-rank test and multivariable analysis was done using Cox proportional hazards model.

RESULTS

From 2000 to 2010, six hundred and twenty-six patients were identified. Type of initial referral (p < 0.0001) and use of neoadjuvant (p = 0.04) and/or adjuvant (p < 0.0001) chemotherapy were significantly different among hospitals. Patients treated with neoadjuvant chemotherapy (n = 108) and those with unresectable disease at laparotomy (n = 5) were excluded from final evaluation. Median overall survival and recurrence-free survival were 74 months (range 63.8 to 84.2 months) and 29 months (range 23.9 to 34.1 months), respectively. For the entire cohort, longer time from Dx to Rx was independently associated with shorter overall survival (hazard ratio = 1.12; 95% CI, 1.06-1.18; p < 0.0001), but not recurrence-free survival. Median overall survival for group 1 was 76 months (range 62.0 to 89.2 months) vs 58 months (range 34.3 to 81.7 months) in group 2 (p = 0.10). Among patients with available data pertaining to adjuvant chemotherapy (N = 457; 318 treated and 139 untreated), overall survival (87 months [range 71.2 to 102.8 months] vs 48 months [range 25.3 to 70.7 months]; p <0.0001), and recurrence-free survival (33 months [range 25.3 to 40.7 months] vs 22 months [range 14.5 to 29.5 months]; p = 0.05) were improved significantly.

CONCLUSIONS

In select patients undergoing initial resection for CRLM, longer time from Dx to Rx is independently associated with worse overall survival. In addition, despite uniform disease characteristics, practice patterns related to definitely resectable CRLM vary significantly across hospitals.

Delay from biopsy to radical prostatectomy influences the rate of adverse pathologic outcomes

BACKGROUND

We sought to determine maximum wait times between biopsy diagnosis and surgery for localized prostate cancer, beyond which the rate of adverse pathologic outcomes is increased.

METHODS

We retrospectively reviewed 4,610 patients undergoing radical prostatectomy between 1990 and 2011. Patients were stratified by biopsy Gleason score and PSA value. For each stratification, χ2 analysis was used to determine the smallest 15-day multiple of surgical delay (e.g., 15, 30, 45…180 days) for which adverse pathologic outcomes were significantly more likely after the time interval than before. Adverse outcomes were defined as positive surgical margins, upgrading from biopsy, upstaging, seminal vesicle invasion, or positive lymph nodes.

RESULTS

Two thousand two hundred twelve patients met inclusion criteria. Median delay was 64 days (mean 76, SD 47). One thousand six hundred seventy-five (75.7%), 537 (24.3%), and 60 (2.7%) patients had delays of <=90, >90, and >180 days, respectively. Twenty-six percent were upgraded on final pathology and 23% were upstaged. The positive surgical margin rate was 24.2% and the positive lymph node rate was 1.1%. Significant increases in the proportion of adverse pathological outcomes were found beyond 75 days in the overall cohort (P = 0.03), 150 days for patients with Gleason <=6, and PSA 0-10 (P = 0.038), 60 days for patients with Gleason 7 and PSA >20 (P = 0.032), and 30 days for patients with Gleason 8-10 and PSA 11-20 (0.041).

CONCLUSION

In low-risk disease, there is a considerable but not unlimited surgical delay which will not adversely impact the rate of adverse pathologic features found. In higher risk disease, this time period is considerably shorter.

Is increased time to diagnosis and treatment in symptomatic cancer associated with poorer outcomes? Systematic review

BACKGROUND

It is unclear whether more timely cancer diagnosis brings favourable outcomes, with much of the previous evidence, in some cancers, being equivocal. We set out to determine whether there is an association between time to diagnosis, treatment and clinical outcomes, across all cancers for symptomatic presentations.

METHODS

Systematic review of the literature and narrative synthesis.

RESULTS

We included 177 articles reporting 209 studies. These studies varied in study design, the time intervals assessed and the outcomes reported. Study quality was variable, with a small number of higher-quality studies. Heterogeneity precluded definitive findings. The cancers with more reports of an association between shorter times to diagnosis and more favourable outcomes were breast, colorectal, head and neck, testicular and melanoma.

CONCLUSIONS

This is the first review encompassing many cancer types, and we have demonstrated those cancers in which more evidence of an association between shorter times to diagnosis and more favourable outcomes exists, and where it is lacking. We believe that it is reasonable to assume that efforts to expedite the diagnosis of symptomatic cancer are likely to have benefits for patients in terms of improved survival, earlier-stage diagnosis and improved quality of life, although these benefits vary between cancers.

Nationwide quality improvement in lung cancer care: the role of the Danish Lung Cancer Group and Registry

INTRODUCTION

To improve prognosis and quality of lung cancer care the Danish Lung Cancer Group has developed a strategy consisting of national clinical guidelines and a clinical quality and research database. The first edition of our guidelines was published in 1998 and our national lung cancer registry was opened for registrations in 2000. This article describes methods and results obtained by multidisciplinary collaboration and illustrates how quality of lung cancer care can be improved by establishing and monitoring result and process indicators.

METHODS

A wide range of indicators was established, validated, and monitored. By registration of all lung cancer patients since the year 2000, data on more than 40,000 patients have been included in the database. Results are reported periodically/quarterly and submitted to formal auditing on an annual basis.

RESULTS

Improvements in all outcome indicators are documented and statistically significant. Thus the 1-year overall survival rate has increased between 2003 and 2011 from 36.6% to 42.7%, the 2-year survival rate from 19.8% to 24.3%, and the 5-year survival rate from 9.8% to 12.1%. Five-year survival after surgical resection has increased from 39.5% to 48.1%. Improvements of waiting times, accordance between cTNM and pTNM, and resection rates are documented.

CONCLUSION

The Danish experience shows that a national quality management system including national guidelines, a database with high data quality, frequent reports, audit and commitment from all stakeholders can contribute to improve clinical practice, improve core results, and reduce regional differences.

Survival after community diagnosis of early-stage non-small cell lung cancer

BACKGROUND

"Rush to surgery" among patients with worse symptoms, delays related to morbidity, and inclusion of patients with advanced disease in study populations have produced a mixed picture of importance of time to treatment to survival of non-small cell lung cancer. Our objective was to assess the contribution of diagnosis to first surgery interval to survival among patients diagnosed in the community with early-stage non-small cell lung cancer.

METHODS

Patients with early-stage lung cancer (N = 174) at the Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins who were diagnosed and treated from 2003 to 2009 and followed through 2011 made up a prospective study of overall survival. Diagnosis to first surgery interval was examined overall, as 2 segments (referral interval and treatment interval), as short and longer intervals, and as a continuous variable.

RESULTS

The majority of patients were female (55%) and aged more than 65 years (61%). The average mean referral and treatment delays were 61.2 and 5.9 days, respectively. Cox method hazard analysis revealed that older age (years) at diagnosis (hazard ratio [HR], 1.02; 95% confidence interval [CI], 1.00-1.05), stage IIB (HR, 2.17; 95% CI, 1.12-4.21), large (>4 cm) (HR, 3.68; 95% CI, 1.05-12.93) or unknown tumor size (HR, 4.45; 95% CI, 1.21-16.38), and weeks from diagnosis to first surgery interval (HR, 1.04; 95% CI, 1.00-1.09) predicted worse overall survival. The threshold period of less than 42 days from diagnosis to surgery did not reach statistical significance.

CONCLUSIONS

Patients seem to benefit from rapid reduction of tumor burden with surgery. Reasons for delay were not available. Nevertheless, referral delay experienced in the community is unduly long. In addition to patient choices, an unconscious patient or physician bias that lung cancer is untreatable or an inevitable consequence of smoking may be operating and needs further investigation.

Timeliness of care and prognosis in patients with lung cancer

BACKGROUND

Timeliness of care is an important dimension of health care quality. The determining factors of less timely care and their influence on the survival of patients with lung cancer (LC) remain uncertain.

AIMS

To analyse the delays in the diagnosis and treatment of LC in our health area, the factors associated with the timeliness of care and their possible relationship with the survival of these patients.

METHODS

A retrospective study was conducted on all patients with a cytohistologically confirmed diagnosis of LC between 1 June 2005 and 31 May 2008. The time delays for consultation (specialist delay), diagnosis (diagnosis delay), and treatment (treatment delay), were analysed, as well as the factors associated with these delays and the influence of the timeliness of care on survival.

RESULTS

A total of 307 cases were included (87 % males). The mean specialist delay was 53.6 days (median 35 days), diagnosis delay 31.5 days (median 18 days), treatment delay 23.5 days (median 14 days). The greater age of the patient and a more advanced stage were associated with a shorter specialist delay. Male sex, a more advanced stage, and poor general status were associated with a shorter treatment delay. The survival is longer in patients with a longer treatment delay.

CONCLUSIONS

The delay in the diagnosis in our population seems to be excessively long. The greater the age, a more advanced tumour stage, male sex, and poor general health status are associated with shorter delays. A longer treatment delay is associated with a longer survival.

Longer waiting times for patients undergoing colorectal cancer surgery are not associated with decreased survival

BACKGROUND AND OBJECTIVES

Wait times are a growing concern in Canada's publicly-funded healthcare system. We sought to determine if increased wait times for colorectal cancer (CRC) treatments resulted in worse outcomes.

METHODS

A population-based retrospective cohort analysis of wait times for CRC patients undergoing major surgical resections in Manitoba, Canada, between 2004 and 2006 was undertaken. Administrative records were utilized to estimate total wait time (TWT), defined as the sum of time from index contact with the healthcare system to diagnosis of CRC (diagnostic wait time [DWT]) and the time from diagnosis to first cancer treatment (treatment wait time [TxWT]). Multivariate Cox regression analysis of 5-year overall survival was performed to determine the effect of TWT quartiles on survival.

RESULTS

One thousand six hundred twenty eight patients with stage I-IV CRC underwent major surgery with a median TWT of 95 days. Predictors of lower 5-year survival included advanced age, higher stage, lower economic status, increased medical comorbidity, urgent presentation, living between 101 and 500 km from the Provincial cancer center, and not receiving adjuvant chemotherapy. After controlling for these variables, TWT quartiles were not associated with survival (P = 0.4898).

CONCLUSIONS

On a population basis, increased TWT was not associated with worse survival, while controlling for important confounders.

Effect of delays on survival in patients with lung cancer

BACKGROUND

The effect on survival of delays in the consultation, diagnostic and treatment processes of lung cancer (LC) is still under debate. The objective of our study was to analyse these time delays and their possible effect on survival.

METHODS

A retrospective study has been performed on all patients in our health area diagnosed with LC (confirmed by cytohistology) over 3 years. The delay in specialist consultation (time between start of symptoms and the first consultation with a specialist), hospital delay (time between first consultation and start of treatment) and overall delay (the sum of the previous two delays) were analysed. The influence of each of these delays was calculated using Cox regression, adjusted for other factors.

RESULTS

A total of 415 patients were included. Of these, 92.5% were male and 75.4% were in stages III-B or IV. The overall delay gave a mean of 123.6 days, the delay in consulting a specialist 82.1 days and the delay in hospitalisation was 41.4 days. A greater overall delay or greater hospital delay was associated with longer survival. No relationship was observed between the specialist consultation delay and survival.

CONCLUSIONS

Globally analysing all the cases and all the stages with LC, it is seen that longer delays are associated with longer survival. This probably reflects the fact that patients with more symptoms are treated more rapidly.

The effect of wait times on oncological outcomes from periampullary adenocarcinomas

BACKGROUND

Overall few patients presenting with periampullary adenocarcinomas have resectable lesions. We postulated that rapid diagnosis and treatment would enhance the likelihood of successful resection, improving survival.

METHODS

A retrospective analysis of patients undergoing surgery for resection of a pancreatic or periampullary lesion was conducted. Resection rate, disease stage and survival were evaluated as a function of wait times.

RESULTS

Pancreatic resections were booked in 355 patients. Of 193 patients with periampullary adenocarcinomas, 119 patients (61.7%) had resectable disease. There was no difference in median time from initial physician consultation to surgery in patients with resectable and unresectable disease (61 days vs. 64 days, respectively). The likelihood of successful resection was virtually identical in patients with wait times ≤ 30 and > 30 days (from surgical consultation to procedure). There was a trend toward a higher T-stage in patients who waited >30 days for surgery (P = 0.055). However, there was no difference in survival as a function of wait time.

CONCLUSIONS

This series does not demonstrate an advantage for rapid diagnosis and surgery, in terms of resection rate and survival. However, further study is required in a larger cohort of patients, to confirm these findings.

The Lean method as a clinical pathway facilitator in patients with lung cancer

INTRODUCTION

Patient flow during workup for lung cancer is often difficult to influence because of delay at many levels: patient delay, doctors' delay and waiting time for X-ray and CT scan, referral to specialist, and waiting time for chemotherapy and radiotherapy or surgery. A mean workup time of 4 months is not unusual.

OBJECTIVES

To improve quality and shorten the workup time for patients with lung cancer.

METHODS

It was decided to employ a program designed by the Toyota car industry, the Lean process, as a tool to improve workup time. A Lean process implicates all levels of an institution with project and focus groups having workshops to analyse present status and suggest improvements.

RESULTS

Since introducing the Lean project, we have decreased the workup time from a mean of 64 days to 16 days, and the median time from diagnosis to surgery was reduced from 26.5 days to 15 days.

CONCLUSION

It is feasible to improve patient flow for patients with lung cancer by employing the Lean method as a pathway instrument.

Timeliness of lung cancer diagnosis and treatment in a rapid outpatient diagnostic program with combined 18FDG-PET and contrast enhanced CT scanning

INTRODUCTION

Delays in the diagnosis of lung cancer are under debate and may affect outcome. The objectives of this study were to compare various delays in a rapid outpatient diagnostic program (RODP) for suspected lung cancer patients with those described in literature and with guideline recommendations, to investigate the effects of referral route and symptoms on delays, and to establish whether delays were related to disease stage and outcome.

METHODS

A retrospective chart study was conducted of all patients with suspected lung cancer, referred to the RODP of our tertiary care university clinic between 1999 and 2009. Patient characteristics, tumor stage and different delays were analyzed.

RESULTS

Medical charts of 565 patients were retrieved. 290 patients (51.3%) were diagnosed with lung cancer, 48 (8.5%) with another type of malignancy, and in 111 patients (19.6%) the radiological anomaly was diagnosed as non-malignant. In 112 (19.8%) no immediate definite diagnosis was obtained, however in 82 of these cases (73.2%) the proposed follow-up strategy confirmed a benign outcome. The median first line delay was 54 days, IQR (interquartile range) 20-104 days, median patient delay 19 days (IQR 4-52 days), median referral delay was 7 days (IQR 5-9 days), median diagnostic delay 2 days (IQR 1-19 days). In 87% a diagnosis was obtained within 3 weeks after visiting a chest physician and 52.5% started curative therapy within 2 weeks after diagnosis. Patients presenting with hemoptysis had shorter first line delays. The RODP care was generally far more timely compared to literature and published guidelines, except for both referral and palliative therapeutic delay. No specific delay was significantly related to disease stage or survival.

CONCLUSIONS

An RODP results in a timely diagnosis well within guideline recommendations. Patient and first line delay account for most of total patient delay. Within the limitations of this retrospective study, we found no association with disease stage or survival.

Prognostic factors in stage IA-IIA cervical cancer patients treated surgically: does the waiting time to the operation affect survival?

PURPOSE

This study aimed to identify prognostic factors in patients with stage IA-IIA cervical cancer who had undergone radical surgery and clarify whether the waiting time to the operation affected the recurrence and survival outcome.

MATERIALS AND METHODS

We retrospectively reviewed the records of 117 patients who underwent surgical resection for stage IA-IIA cervical cancer. Patients were subdivided based on the waiting time from the initial visit to a gynecologist until surgery. Univariate analyses were performed to evaluate factors associated with recurrence-free and overall survival.

RESULTS

The mean time from the first visit to surgery was 48 days (range 20-92). Recurrence-free and overall survival rates were not affected by the waiting time to the operation. On univariate analysis, lymph node metastasis (p = 0.003) and lymph-vascular space invasion (p = 0.015) were prognostic predictors of progression-free survival, while the waiting time to the operation was not (p = 0.106). Lymph node metastasis (p = 0.007), lymph-vascular space invasion (p = 0.046), and the histological diagnosis (p = 0.027) were prognostic predictors of overall survival, but the waiting time to the operation was not (p = 0.653).

CONCLUSIONS

The waiting time to the operation from the initial visit to surgical intervention does not adversely affect the outcome of cervical cancer within the time frames analyzed in this study. Furthermore, surgery allows the status of the lymph nodes and lymph-vascular space invasion, dependent variables associated with survival, to be assessed accurately.

Increasing time delay from presentation until surgical referral for hepatobiliary malignancies

BACKGROUND

Studies have shown that delayed treatment of several non-hepatobiliary (HB) malignancies is associated with adverse effects on disease progression and survival. Delayed treatment of HB malignancies has not been thoroughly investigated.

METHODS

We performed a retrospective institutional review of patients referred to the Hepatobiliary Surgery Service at Beth Israel Deaconess Medical Center (BIDMC) for hepatobiliary malignancies from 2002 to 2008. Primary outcomes included the time delays (TD) in patient workup. Secondary outcomes were reasons for delay as well as disparities in TD based on demographic factors.

RESULTS

Multivariate-adjusted linear regression showed a significant trend of increasing time from presentation until referral to a HB surgeon over the 7-year period (P= 0.001). There were no differences in TD by gender, age or education level. Multivariate-adjusted linear regression showed a significant trend of increasing number of imaging tests performed prior to referral [computerized tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET) and ultrasound and endoscopic ultrasound (US/EUS)] (P < 0.001). Multivariate-adjusted linear regression in resectable patients showed a significant difference in overall length of survival in those with a TD1 > 30 days compared with those with a TD1 (TD from presentation until referral) <30 days (P = 0.042).

CONCLUSIONS

Delays were associated with an increase in imaging studies and delays adversely affect survival in resected patients. Referring physicians are encouraged to expedite the evaluation and early referral of all patients to an HB surgeon for evaluation and treatment.

Nurses as patient navigators in cancer diagnosis: review, consultation and model design

The diagnostic phase of cancer care is an anxious time for patients. Patient navigation is a way of assisting and supporting individuals during this time. The aim of this review is to explore patient navigation and its role in the diagnostic phase of cancer care. We reviewed the literature for definitions and models of navigation, preparation for the role and impact on patient outcomes, specifically addressing the role of the nurse in patient navigation. Interviews and focus groups with healthcare providers and managers provided further insight from these stakeholder groups. Common to most definitions of navigation is the navigator's multifaceted role in facilitating processes of care, assisting patients to overcome barriers and providing information and support. Navigation may be provided by laypersons, clerical staff and/or healthcare professionals. In the diagnostic phase it has the potential to affect efficiency of diagnostic testing, patients' experience during this time and preparation for decision-making around treatment options. Patient care during the diagnostic phase requires various levels of navigation, according to individual informational, physical and psychosocial needs. Identifying those individuals who require more support--whether physical or psychosocial--during the diagnostic phase is of critical importance.

Wait times from presentation to treatment for colorectal cancer: a population-based study

BACKGROUND

The wait time from cancer diagnosis to treatment has been a recent focus of cancer care in Canada.

OBJECTIVE

To examine the trends in wait times from patient presentation to treatment (overall health system wait time [OWT]) for colorectal cancer (CRC).

METHODS

Patients with colorectal adenocarcinomas, diagnosed between 2001 and 2005, and their first definitive treatments were identified from the population-based Manitoba Cancer Registry (Winnipeg, Manitoba). By linkage to Manitoba Health and Healthy Living's administrative databases, a patient's first gastrointestinal investigation (abdominal radiological imaging, lower gastrointestinal endoscopy or fecal occult blood test) before CRC diagnosis was identified. The index contact with the health care system was estimated from the date of the visit with the physician who ordered the first gastroenterological investigation. The OWT was defined as the time from the index contact to the first treatment, while diagnostic delay was defined as the time from the index contact to the diagnosis of CRC. Multivariate Cox regression analysis was performed to determine independent predictors of OWT.

RESULTS

The OWT was estimated for 2552 cases of CRC over the five years that were examined. The median OWT increased from 61 days in 2001 to 95 days in 2005 (P<0.001). Most of the increase was in diagnostic wait times (median of 44 days in 2001 versus 64 days in 2005 [P<0.001]). Year of diagnosis, older age, urban residence and diagnosis at a teaching facility were independent predictors of OWT.

CONCLUSIONS

The OWT from presentation to treatment of CRC in Manitoba steadily increased between 2001 and 2005, mostly due to diagnostic delays.

Lung cancer diagnostic and treatment intervals in the United States: a health care disparity?

INTRODUCTION

Lung cancer diagnostic and treatment delays have been described for several patient populations. However, few studies have analyzed these intervals among patients treated in contemporary health care systems in the United States. We therefore studied the timing of lung cancer diagnosis and treatment at a U.S. medical center providing care to a diverse patient population within two different hospital systems.

METHODS

We performed a retrospective analysis of consecutive patients diagnosed with non-small cell lung cancer stage I to III from 2000 to 2005 at public and private hospitals affiliated with the University of Texas Southwestern Medical Center. We recorded patient and disease characteristics; dates of initial radiograph suspicious for lung cancer, diagnosis, and treatment; and overall survival. Associations between these factors were assessed using univariate analysis, multivariate logistic regression, and Kaplan-Meier survival analysis.

RESULTS

A total of 482 patients met criteria for analysis. In univariate analyses, the image-treatment interval was significantly associated with race, age, income, insurance type, and hospital type (76 days for public versus 45 days for private; p < 0.0001). In multivariate analysis, only hospital type remained significantly associated with the image-treatment interval; patients in the private hospital setting were more likely to receive timely treatment (hazard ratio 1.85; 95% confidence interval, 1.37-2.50; p < 0.001). In univariate analysis, the image-treatment interval was not associated with disease stage (p = 0.27) or with survival (p = 0.42).

CONCLUSION

Intervals between suspicion, diagnosis, and treatment of lung cancer vary widely among patients. Health care system factors, such as hospital type, largely account for these discrepancies. In this study, these intervals do not appear to be associated with clinical outcomes.

Lung cancer: a biologically different disease in women?

Lung cancer is now the leading cancer killer of women, having surpassed breast cancer in 1987. Over 30,000 more US women are expected to die from lung cancer than from breast cancer annually. The vast majority of lung cancer cases are attributable to smoking, and smoking prevalence rates remain unacceptably high in US women. Mounting evidence suggests that there are significant differences in lung cancer between the sexes. Although the magnitude of the effect of smoking on the development of lung cancer may not be different, smoking appears to have an impact on the histology of lung cancer. Hormonal and biologic effects may play a role in lung cancer carcinogenesis, and may impact treatment response. A more thorough understanding of the biologically different aspects of lung cancer across different populations may lead to innovations in prevention and treatment.

Time to treatment in patients with stage III non-small cell lung cancer

PURPOSE

To determine whether time to treatment (TTT) has an effect on overall survival (OS) in patients with unresectable or medically inoperable Stage III non-small cell lung cancer (NSCLC) and whether patient or treatment factors are associated with TTT.

METHODS AND MATERIALS

Included in the study were 237 consecutive patients with Stage III NSCLC treated at University of Michigan Hospital (UM) or the Veterans Affairs Ann Arbor Healthcare System (VA). Patients were treated with either palliative or definitive radiotherapy and radiotherapy alone (n = 106) or either sequential (n = 69) or concurrent chemoradiation (n = 62). The primary endpoint was OS.

RESULTS

Median follow-up was 69 months, and median TTT was 57 days. On univariate analysis, the risk of death did not increase significantly with longer TTT (p = 0.093). However, subset analysis showed that there was a higher risk of death with longer TTT in patients who survived >or= 5 years (p = 0.029). Younger age (p = 0.027), male sex (p = 0.013), lower Karnofsky Performance Score (KPS) (p = 0.002), and treatment at the VA (p = 0.001) were significantly associated with longer TTT. However, on multivariate analysis, only lower KPS remained significantly associated with longer TTT (p = 0.003).

CONCLUSION

Time to treatment is significantly associated with OS in patients with Stage III NSCLC who lived longer than 5 years, although it is not a significant factor in Stage III patients as a whole. Lower KPS is associated with longer TTT.

Waiting times in early-stage non-small cell lung cancer (NSCLC)

INTRODUCTION

Wait times in cancer care continue to be an important clinical, social, and political issue. This study examines wait times along the care path from suspicious imaging study (Detection) to adjuvant chemotherapy initiation (Chemotherapy) for patients with early-stage non-small cell lung cancer (NSCLC) who undergo surgical resection.

METHODS

A retrospective chart review of patients diagnosed in 2005 with NSCLC who underwent curative-intent surgery in Nova Scotia, Canada was conducted to abstract dates of care events (Detection, Surgery Consultation, Surgery, Medical Oncology [MO] Referral, MO Consultation and Chemotherapy) and patient characteristics. Multifactorial regression methods were used to identify statistically-significant cofactors associated with wait times at various resolutions of care intervals (low, intermediate, high).

RESULTS

A median wait time of 141 days elapsed between Detection-Chemotherapy; and a median 107 and 52 days elapsed between Detection-Surgery and Surgery-Chemotherapy, respectively. A number of demographic, clinical, epidemiological, and system resource dependant factors influenced wait times at different resolutions, and were best detailed utilizing high resolution analysis. Wait time between MO referral-MO Consultation was inversely related to that experienced in the preceding interval of Surgery-MO Referral.

CONCLUSIONS

This study provides a first detailed examination of wait times experienced by NSCLC patients undergoing curative-intent surgery according to care interval definitions; demonstrates the value of high care interval resolution analysis to detect bottlenecks in access to care; and reports on the interdependence of elapsed times between care events along the care path for cancer patients.