Predicting delays in lung cancer diagnosis and staging

Factors influencing the timeliness of care for patients with lung cancer in Bangladesh

BACKGROUND

This study explored the factors associated with timeliness of care in the healthcare seeking pathway among patients with lung cancer in Bangladesh.

METHODS

A structured questionnaire was used for data collection from 418 patients with lung cancer through face-to-face interviews in three tertiary care hospitals. Log-rank tests were performed to test differences in the length of intervals between points in healthcare by socioeconomic characteristics and care seeking behaviours of the patients. Cox Proportional Hazard (PH) regression analysis was performed to identify the predictors of the intervals after adjustment for variations in other variables.

RESULTS

A higher education level was associated significantly (p < 0.05) with a shorter interval between first contact with a healthcare provider (HCP) and diagnosis (median 81 days) and initiation of treatment (median 101 days). Higher monthly household income was associated significantly with a shorter time from first contact and diagnosis (median 91 days), onset of symptom and diagnosis (median 99 days), onset of symptom and treatment (median 122 days), and first contact with any HCP to treatment (median 111 days). Consulting with additional HCPs prior to diagnosis was associated significantly with longer intervals from first contact with any HCP and diagnosis (median 127 days), onset of symptom and diagnosis (median 154 days), onset of symptom and treatment (median 205 days), and first contact with any HCP to treatment (median 174 days). Consulting with informal HCPs was associated significantly with a longer time interval from symptom to treatment (median 171 days). Having more than one triggering symptom was associated significantly with a shorter interval between onset of symptoms and first contact with any HCP.

CONCLUSION

The predictors for timeliness of lung cancer care used in this study affected different intervals in the care seeking pathway. Higher education and income predicted shorter intervals whereas consulting informal healthcare providers and multiple providers were associated with longer intervals.

The Emerging Boon of Information and Communication Technology in Multidisciplinary Cancer Care: A Force Multiplier With a Human Touch

Cancer care (CC) is incredibly complex and requires the coordination of multiple disciplines for optimal outcomes. Historically, this has been accomplished with multidisciplinary tumor boards (MDTBs), but the benefits, while perhaps intuitive, have not always been demonstrated with sufficient research robustness and validity. We hypothesize that this difficulty in demonstrating the benefit of MDTBs may be related to a delay in decision-making and operationalizing those decisions. The history and value of MDTBs are presented as well as their weaknesses and limited demonstration of improved outcomes. A major weakness highlighted by the challenges of MDTBs is the concept of total package time (TPT) (rather, the inability to keep it as short as possible); any significant delays in CC for any discipline may have a deleterious impact on any given patient's care outcome. Drawing on our own experience with utilizing information and communication technology (ICT) during an effort to apply accountability theory to improve specifically radiation therapy package time (RTPT), we argue that similar principles will be applicable in the improvement of not only the TPT which relies on multiple disciplines, but other factors of CC as well, such as coordination. Experience with improvement in RTPT is discussed and the underlying theory is demonstrated as a sound methodology to apply beyond RTPT to TPT involving coordination of multiple disciplines and stands to lead to the full realization of the benefits of the multidisciplinary approach. The complexity of cancer means that real solutions to optimal outcomes are also, by nature, complex, but here simple accountability theory is demonstrated that may unlock the next phase of multidisciplinary coordination. In this work, we argue that the benefits of the MDTB format can be fully realized with the addition of ICT, a technological breakthrough in the past two decades, while not forgetting about continued human factors.

A Pilot Analysis of Circulating cfRNA Transcripts for the Detection of Lung Cancer

Lung cancers are the leading cause of cancer-related deaths worldwide. Studies have shown that non-small cell lung cancer (NSCLC), which constitutes the majority of lung cancers, is significantly more responsive to early-stage interventions. However, the early stages are often asymptomatic, and current diagnostic methods are limited in their precision and safety. The cell-free RNAs (cfRNAs) circulating in plasma (liquid biopsies) offer a non-invasive detection of spatial and temporal changes occurring in primary tumors since the early stages. To address gaps in the current cfRNA knowledge base, we conducted a pilot study for the comprehensive analysis of transcriptome-wide changes in plasma cfRNA in NSCLC patients. Total cfRNA was extracted from archived plasma collected from NSCLC patients (N = 12), cancer-free former smokers (N = 12), and non-smoking healthy volunteers (N = 12). Plasma cfRNA expression levels were quantified by using a tagmentation-based library preparation and sequencing. The comparisons of cfRNA expression levels between patients and the two control groups revealed a total of 2357 differentially expressed cfRNAs enriched in 123 pathways. Of these, 251 transcripts were previously reported in primary NSCLCs. A small subset of genes (N = 5) was validated in an independent sample (N = 50) using qRT-PCR. Our study provides a framework for developing blood-based assays for the early detection of NSCLC and warrants further validation.

Real-World Journey of Unresectable Stage III NSCLC Patients: Current Dilemmas for Disease Staging and Treatment

Daily-practice challenges in oncology have been intensified by the approval of immune checkpoint inhibitors (ICI). We aimed to outline current therapy policies and management of locally advanced unresectable stage III non-small-cell lung cancer (NSCLC) in different countries. One thoracic oncologist from each of the following countries—Belgium, Croatia, Greece, Israel, the Netherlands, Norway, Poland, Portugal, Romania, Slovenia, and Switzerland—participated in an electronic survey. Descriptive statistics were conducted with categorical variables reported as frequencies and continuous variables as median and interquartile range (IQR) (StataSE-v15). EBUS (endobronchial ultrasound bronchoscopy) was used either upfront or for N2 confirmation. Resectability is still a source of disagreement; thus, decisions vary within each multidisciplinary team. Overall, 66% of stage III patients [IQR 60–75] undergo chemoradiation therapy (CRT); concurrent CRT (cCRT) accounts for most cases (~70%). Performance status is universally used for cCRT eligibility. Induction chemotherapy is fairly weighted based on radiotherapy (RT) availability. Mean time to evaluation after RT completion is less than a month; ICI consolidation is started within six weeks. Durvamulab expenditures are reimbursed in all countries, yet some limiting criteria exist (PD-L1 ≥ 1%, cCRT). No clear guidance on therapies at Durvamulab progression exist; experts agree that it depends on progression timing. Given the high heterogeneity in real-world practices, standardized evidence-based decisions and healthcare provision in NSCLC are needed.

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.

Factors associated with delayed treatment initiation in an unselected cohort of patients with small-cell lung cancer

BACKGROUND

Small-cell lung cancer (SCLC) is an aggressive, rapidly progressive malignancy. Thus, expedient diagnosis and treatment initiation is important. This study identifies and quantifies factors associated with delayed diagnosis and treatment initiation in patients with SCLC and compares time to treatment in SCLC with a cohort of patients with non-small cell lung cancer (NSCLC).

MATERIALS AND METHODS

The study included all patients diagnosed with SCLC at a hospital in southern Norway in a ten-year period (2007-2016), and all NSCLC patients during the period 2013-2016. Total time to treatment (TTT), was defined as the number of days from date of referral due to suspicion of lung cancer to first day of treatment. Factors associated with prolonged TTT were estimated using multivariate median regression analysis.

RESULTS

The median TTT and interquartile range (IQR) for the 183 patients with SCLC was 16 (10-23) days. Factors associated with delayed TTT included outpatient versus inpatient evaluation (+8.4 days), number of diagnostic procedures (+4.3 days per procedure), stage I-III versus stage IV (+3.6 days) and age (+2.1 days per 10 years). In 2013-16, TTT in SCLC was 3.5 days shorter than in the period before and less than half that of NSCLC in the same period, 15 (9-22) versus 33 (22-50) days (p = 0.001).

CONCLUSION

Shorter TTT is seen in higher stage, while longer TTT is a result of increasing complexity of the diagnostic process and treatment decisions of patients with curative intent treatment. Knowledge on delaying factors can shorten TTT and improve clinical practice.

Limitations and perceived delays for diagnosis and staging of lung cancer in Portugal: A nationwide survey analysis

BACKGROUND

We aimed to identify the perception of physicians on the limitations and delays for diagnosing, staging and treatment of lung cancer in Portugal.

METHODS

Portuguese physicians were invited to participate an electronic survey (Feb-Apr-2020). Descriptive statistical analyses were performed, with categorical variables reported as absolute and relative frequencies, and continuous variables with non-normal distribution as median and interquartile range (IQR). The association between categorical variables was assessed through Pearson's chi-square test. Mann-Whitney test was used to compare categorical and continuous variables (Stata v.15.0).

RESULTS

Sixty-one physicians participated in the study (45 pulmonologists, 16 oncologists), with n = 26 exclusively assisting lung cancer patients. Most experts work in public hospitals (90.16%) in Lisbon (36.07%). During the last semester of 2019, responders performed a median of 85 (IQR 55-140) diagnoses of lung cancer. Factors preventing faster referral to the specialty included poor articulation between services (60.0%) and patients low economic/cultural level (44.26%). Obtaining National Drugs Authority authorization was one of the main reasons (75.41%) for delaying the begin of treatment. The cumulative lag-time from patients' admission until treatment ranged from 42-61 days. Experts believe that the time to diagnosis could be optimized in around 11.05 days [IQR 9.61-12.50]. Most physicians (88.52%) started treatment before biomarkers results motivated by performance status deterioration (65.57%) or high tumor burden (52.46%). Clinicians exclusively assisting lung cancer cases reported fewer delays for obtaining authorization for biomarkers analysis (p = 0.023). Higher waiting times for surgery (p = 0.001), radiotherapy (p = 0.004), immunotherapy (p = 0.003) were reported by professionals from public hospitals.

CONCLUSIONS

Physicians believe that is possible to reduce delays in all stages of lung cancer diagnosis with further efforts from multidisciplinary teams and hospital administration.

A Multidisciplinary Lung Cancer Program: Does It Reduce Delay Between Diagnosis and Treatment?

INTRODUCTION

Lung cancer is the leading cause of cancer death in the USA, claiming more than 140,000 deaths annually. Delays in diagnosis and treatment can lead to missed opportunities for both curative and life prolonging therapies. This study aimed to evaluate duration of time to diagnosis and first treatment, as well as investigate reasons for delays in care.

METHODS

This retrospective study included all lung cancer cases diagnosed by Stony Brook's Lung Cancer Evaluation Center (LCEC) between 2013 and 2019. Demographic, radiologic, pathologic and clinical variables were investigated, including cancer staging, histology, and medical and family histories. Evaluations included the determination of median time from initial encounter to diagnosis, median time from diagnosis to start of treatment and an exploration of the factors that influence possible causes for delays in care.

RESULTS

The LCEC's comprehensive multidisciplinary lung nodule program yielded a median length of time from CT to PET of 11 days, PET to procedure of 13 days, procedure to treatment consult of 9 days, and from consult to treatment of 9 days. LCEC patients experienced an overall median of 44 days from initial presentation to first treatment compared to the national ideal of 62 days, thereby representing a 29% reduction in time from first CT to onset of treatment.

CONCLUSION

Delays in lung cancer diagnosis and treatment can negatively impact patient morbidity and mortality. This study suggests that a coordinated multidisciplinary lung cancer program may reduce delays in care, thereby improving patient outcomes.

Lung cancer recurrence and mortality outcomes over a 10-year period using a multidisciplinary team approach

BACKGROUND

Longitudinal data are limited regarding the impact of a multidisciplinary team (MDT) approach on patient outcomes among those diagnosed with lung cancer. The purpose of this study is to 1) compare 1- and 3-year recurrence and mortality rates among patients receiving a MDT vs. standard model of care; and 2) assess trends in these proportions over a 10-year period.

METHODS

This investigation included 2044 lung cancer cases reported to the Stony Brook Cancer Registry between 2006 and 2015. Patients were stratified into 2 groups, those participating in Stony Brook's Lung Cancer Evaluation Center's (LCEC) MDT Program (n = 1179) and those receiving a standard model of care (n = 865). 1- and 3-year stage-stratified recurrence and mortality rates are reported. Logistic regression analyses are performed and linear by linear associations are used to assess trends over time.

RESULTS

A higher proportion of patients in the MDT program (LCEC) remained disease-free at 1-year compared those receiving standard care (80.0 % vs 62.3 %, p < 0.01). There were no significant changes in mortality over the 10-year observation period in either group, however the rates were significantly lower among LCEC vs non-LCEC cases after adjusting for possible confounders (OR = 0.68 (0.51,0.90) at 1-year; OR = 0.50 (0.36, 0.70) at 3-years). Recurrence was also lower at 3-years in the MDT group (OR = 0.51 (0.32, 0.79)).

CONCLUSIONS

This study suggests that a comprehensive MDT program for lung cancer yields improved patient outcomes compared to the standard model of care and this approach may help to decrease rates of disease recurrence and mortality.