Wait Times for Cancer Surgery in the United States

Trends and Predictors of Delays

Karl Y. Bilimoria, MD, MS; Clifford Y. Ko, MD,MS, MSHS; James S. Tomlinson, MD; Andrew K. Stewart, MA; Mark S. Talamonti, MD; Denise L. Hynes, RN, PhD; David P. Winchester, MD; David J. Bentrem, MD, MS

Disclosures

Annals of Surgery. 2011;253(4):779-785. 

In This Article

Discussion

In 1999, the Institute of Medicine in their report Crossing the Quality Chasm defined 6 domains of quality health care.[32] Timeliness of care is one of these important areas and is a proxy for unmeasured aspects of a health care system such as how hospitals handle excess case volume, efficiency of the system, and the availability of resources. Time to treatment has been shown to be an important quality indicator for cerebrovascular and coronary interventions as well as for cancer care.[33,34] A number of reports have shown that diagnosis or treatment delays result in major psychosocial stresses for cancer patients,[17–19] although there is a paucity of definitive evidence that such delays result in worse clinical outcomes. With an aging population, the demand for health services for cancer will continue to increase. We found that wait times in the United States for 8 common solid organ malignancies had increased over time and were considerably longer at NCI-designated cancer centers and VA hospitals.

International Comparisons

There is wide international variation on the time to cancer treatment.[35–39] The UK National Health Service Cancer Plan in 2000 recommended a maximum wait time of 1 month from diagnosis to treatment for all cancers.[40] Similarly, the Canadian Society of Surgical Oncology recommended a time interval of less than 2 weeks from diagnosis to surgery.[41] A Canadian study demonstrated increasing wait times for surgery from 1993 to 2000 for breast, colorectal, and lung cancer.[41] From 1995 to 2005, we found that the median time from diagnosis to treatment had increased significantly for each of the 8 tumor sites in the United States. Examining patients treated in 2000, another Canadian study demonstrated considerably longer wait times for breast, colorectal, and thoracic malignancies comparable to our findings.[42] In the most recent time period, 2003–2005, we found that median wait times from diagnosis to first treatment ranged from 14 days for colon cancer patients to 40 days for patients with primary liver tumors.

Effect of Center Type

Prior studies have demonstrated that wait times vary by cancer center type.[42] Patients have been shown to have longer wait times at academic centers.[43] In Britain, wait times for patients with breast and colorectal cancer were longer at cancer centers.[38] When examining lung cancer at VA hospitals using international studies as a comparison group, Schultz et al concluded that wait times were comparable at VA and non-VA centers.[44] Similarly, the VA Office of Quality and Performance did not find a considerable difference in the timeliness of treatment of patients with colorectal cancer.[45] We found that center type was significantly associated with wait times. Community hospitals had the shortest times from diagnosis to first treatment for every tumor site, whereas NCI-CCC and VA centers generally had longer wait times. When examining those patients who were diagnosed and treated at the same hospitals (minimizing the effect of referrals), we found that the differences by center persisted, though they were less pronounced for NCI-CCC. The effect of increased case load at NCI-CCC centers through potential regionalization and at VA hospitals through a growing veteran population will likely increase the time from diagnosis to treatment.[46–48] Thus, increased resources and additional strategies are needed to ensure timely care for patients treated at NCI-CCC and VA centers.

Effect of Tumor Stage

Comber et al[49] examined times between referral and treatment for 5 common cancers and found that patients with longer wait times generally had less advanced disease and therefore better survival, suggesting that their "typical delays" were not of clinical significance. For patients with nonsmall cell lung cancer, Liberman et al[50] did not find a difference in stage distribution with prolonged wait times. We found that earlier stage patients had longer intervals from diagnosis to treatment. For 7 of the 8 sites, patients were more likely to have with wait time >30 if they had Stage I disease (compared with Stage III).

Effect of Patient Factors

When examining patient and provider factors that predispose to treatment delays after the diagnosis of breast cancer, Richards et al[37] found that older age was the only factor that strongly correlated with treatment delay. Simunovic et al[42] found an association between age and prolonged wait times for several tumor sites including breast, colon, lung and prostate.[41] Studies have also demonstrated increased wait times according to race.[51] Similarly, we found on multivariable analysis that patients were generally more likely to experience a wait time of > 30 days from diagnosis to first treatment if they were older or black.

Quality improvement initiatives are currently underway internationally and at VA centers. Lo et al[52] documented the effect of implementing a "Time to Treat Program" for patients diagnosed with lung cancer as part of the Ontario Wait Times Strategy. Through the creation of a navigator position to coordinate care of patients during the diagnostic workup, the median time from suspicion of lung cancer to diagnosis decreased from 128 days to 20 days. In the United Kingdom, the Labour government in 1997 instituted a "war on waiting" to lower the 1.3 million patients on the National Health Service waiting list.[53] In 2000, they reached an initial goal of reducing the number of people on the list by 100,000. Shultz et al[54,55] examined characteristics of VA centers associated with timeliness of care for lung cancer. Few interventions they examined in the literature successfully improved the timeliness of lung cancer care.[56,57] They found centers performing patient flow analyses and centers with a Chief of Staff focused on wait times had shorter times to diagnoses and treatment. Efforts to implement a Cancer Navigator Program are underway at VA centers to help guide patients through the diagnostic process to minimize loss to follow up and to help ensure timely, efficient care.[58,59] In addition, reducing disparities in access to care and utilizing multidisciplinary clinics have also been suggested as opportunities to decrease wait times for cancer surgery in the United States.[60,61] Thus, there is a need for support programs to ensure "at-risk" patient populations have access to timely treatment.

Limitations

The results of this study should be interpreted with consideration of certain limitations. First, the definition of the diagnosis date may be ambiguous in certain circumstances. We assessed whether there were systematic differences according to the specific hospital, but none were evident. Second, the NCDB is a large multi-institutional dataset. We evaluated for systematic miscoding by hospitals and found no evidence of this at individual centers. Hospitals undergo audits every 3 years to assess the accuracy of the submitted data. Third, our results may not be generalizable to all hospitals and may only be applicable to hospitals approved by the Commission on Cancer.[62] Commission on Cancer-approved hospitals are typically larger and have a higher level of cancer-related specialists and services compared with nonapproved hospitals. This leads to a selection bias where minorities and those with low incomes are slightly underrepresented. Fourth, advancements in screening and early detection may partly explain the increasing wait times as fewer patients present with acute disease requiring a relatively short interval between diagnosis and treatment. However, we excluded patients who underwent surgery within 24 hours of diagnosis to minimize this issue. Moreover, changes in diagnostic, staging, and treatment modalities may also partly explain the increasing delays over time. Finally, although wait times are increasing and longer at certain centers, it is unknown whether increased wait times affect survival and what specific duration of delay leads to worse outcomes. We did not examine this issue as cancer registries contain insufficient information to understand the extent of preoperative evaluations and postoperative complications.

Conclusion

Despite these limitations, wait times for cancer surgery have increased over 20% in the last decade and are likely to continue to increase. There is a need for continued monitoring and the development of programs directed at education, prevention, screening, and to help at-risk patients navigate an increasingly complex healthcare environment. As case volumes increase at NCI-CCC and VA hospitals, wait times are likely to further increase. Thus additional resources are needed to support these centers with growing patient populations.

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