Many U.S. patients with head and neck cancer have lengthy treatment delays that increase their chances of dying of their disease, according to a new study by Fox Chase Cancer Center researchers.
The analysis also found evidence of a dilemma that faces cancer patients in general: Getting care at leading medical centers can improve survival, but pursuing that care can add to delays.
As any patient knows, it takes time to get referrals, second opinions, advanced diagnostic tests, and a treatment spot at a major medical center.
"You don't want people thinking they need to rush to treatment, but the timing needs to be optimized," said Fox Chase radiation oncologist Colin T. Murphy, lead author of the study in the current Journal of Clinical Oncology. "We need to get these patients in faster."
The issue of prolonged times between diagnosis and treatment is hardly new. The Institute of Medicine, which advises the government on health policy, cited timeliness of care as a key indicator of quality in its 2001 report on the nation's health-care delivery system.
More recently, some researchers have looked at whether delays in cancer therapy worsen prognoses.
The question is particularly important with head and neck cancers, Murphy said, because the tumors grow rapidly. Patients who put off treatment may have more advanced disease, which can worsen survival chances. But even with prompt treatment, the complexity often requires time-consuming planning.
"These are complicated cases," Murphy said. "Patients may need to consult with reconstructive surgeons, speech pathologists, dentists."
Head and neck cancers are relatively rare, but the incidence has been increasing for more than a decade, largely because a greater proportion are linked to HPV (human papillomavirus) infections.
Using a national cancer database, Murphy and his coauthors identified 51,655 patients who were diagnosed with cancer of the tongue, throat, or larynx between 1998 and 2011. The database included information about the type of medical facility and patient demographics.
The interval between diagnosis and treatment steadily increased during that period, from a median of 19 days in 1998 to 30 days in 2011, the researchers found.
Patients who got treatment within about 46 days had the optimal survival rate, with half living more than 72 months.
But when treatment was delayed beyond 46 days - as it was for a quarter of patients in 2011 - survival rates began to fall. For patients who started treatment within 53 to 67 days, the median survival was 61 months (meaning half were alive, half had died). For those who waited more than 67 days for treatment, median survival fell to 46.6 months.
"Greater than 67 days is too long and should be considered unacceptable," the authors wrote. "Treatment must begin more expeditiously."
But they also acknowledged that the growing interval between diagnosis and treatment "is an insidious phenomenon, caused in large part by the pursuit of improved care."
For example, delays greater than 46 days were more common among patients treated at academic medical centers and specialized radiation facilities. The researchers speculated that these patients likely lost time to "care transitions" - getting appointments and transferring medical records.
Another logjam Murphy said he sees in his practice involves insurance authorization.
"PET scans are ordered a lot in head and neck cancers," he said. "It can take two or three weeks to get an OK" for the expensive test from an insurer.
The researchers stressed that their findings "should not be misinterpreted to suggest" getting a second opinion or going to top-notch centers is detrimental to survival. The excellence of treatment at such centers "mitigates some portion" of the higher death risk related to long wait times.
So how to expedite lifesaving care? One strategy is next-day appointments for new patients. Fox Chase recently adopted this "rapid access" system. Thomas Jefferson University Hospital offers it, too.
"I get calls on my cellphone all the time" from community-based doctors referring patients, said surgeon David M. Cognetti, codirector of Jefferson's Center for Head and Neck Surgery. "We call the patient and get them right in."
Denmark, which has a national health system, adopted a policy of fast-tracked care after research linked long wait times to tumor progression in head and neck cancer patients. By coordinating diagnosis, evaluation, and therapy, pretreatment time was cut from a median of 69 days in 2002 to 41 days in 2010.
"Without such reforms," Murphy and his coauthors conclude, "it is conceivable that outcomes will continue to worsen because of prolonged time to treatment initiation."