A study published in the August print issue of the Journal of Oncology Practice shows that from 1998-2008, wait times for colorectal cancer operations at Veterans Administration hospitals increased from 19 to 32 days. But researchers think longer waits may be a reflection of several unmeasured variables including more careful care, staffing, and patient conditions or preferences.
"Some of it is purely staffing – we don't have enough surgeons or nurses or anesthetists or O.R. time to meet the need," says Martin McCarter, MD, investigator at the University of Colorado Cancer Center and surgical oncologist at the University of Colorado Hospital. "But some of this increase in wait times for cancer procedures at the VA may be due to an increased focus on quality and outcomes. Better care takes time."
The study used data from 17,487 patients listed in the VA Central Cancer Registry. McCarter and colleagues including first author Ryan Merkow, MD, former surgery resident at UCH, compared the time between diagnosis and definitive, cancer-directed therapy such as colectomy or rectal resection in 1998 and 2008. During this 10-year period, the median time from diagnosis to treatment increased from 19 to 32 days. At high-volume centers, increases were even more pronounced, jumping 14 days for the treatment of colon cancer and nearly 30 days for the treatment of rectal cancer.
"What's missing in this study are any cancer-related outcomes – what's the effect of these longer wait times on survival or quality of life?" says McCarter. Reframed, the question is whether more careful care is worth the wait – is it better to treat quickly in the days after diagnosis or to adopt the more modern, more careful approach that can push back treatment?
"For example, perhaps more VA doctors are taking into account a patient's comorbidities – maybe someone has lung or heart problems in addition to cancer. And it can take a few days or even a few weeks to bring specialists for these other conditions onboard," McCarter says. McCarter points out that this question of the influence of time-to-treatment on outcomes is a larger question in the overall strategy of cancer care. "Although everybody assumes it's best to treat cancer as soon as possible, by the time they're detected, most tumors have been growing for years. It may be that a two-week delay before treatment makes no difference and that taking time to better plan care is a worthwhile trade," McCarter says.
The study also shows that patient, tumor and hospital factors influence time to treatment. Specifically, patients over age 55 were treated slightly more quickly than younger ones, and more advanced tumors were treated more quickly than less advanced ones – both findings match the intuitive need to treat a more dangerous tumor efficiently. But then married (vs. unmarried) and white (vs. black) patients treated at low-volume (vs. high-volume) centers, and at the same hospital at which they were diagnosed also saw shorter wait times between diagnosis and treatment. Some of these factors may reflect other unmeasured influences such as a patient's desire for a second opinion before committing to surgery.
"VA's across the country realize that timeliness of care is an important issue. There's tremendous pressure to move people efficiently through the system. For example, wait times for an elective hernia repair may be up to 9 months because cancer patients take priority over elective or more benign situations and there just aren't enough resources to go around," McCarter says.
"The challenge for the future is to have our cake and eat it too – to have quality along with the efficiency of shorter wait times," McCarter says.
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