12 Oct Cancer: A Story Of Time MAtters To Patients & Healthcare Systems

Since the mid 1990’s, delays in patients beginning treatment for cancer care have been increasing. As the population of the U.S. continues, more people will continue to be diagnosed with cancer, and as new therapies continue to extend survival rates, the demand for health services focusing on cancer will continue to increase and stress the healthcare system.
In the below chart you can see how the time it takes from a patient having a biopsy, being informed that they have cancer, getting schedule to see the appropriate physicians, and beginning treatment has continued to increase.  (granted the below data points are 8 years old, but it shows the direction that we are experiencing)

Another complexity is the size and intricacies with in the healthcare system. Currently our healthcare system is experiencing massive changes in their size and scope. With mergers, acquisitions, and consolidation healthcare systems are trying to increase the opportunity to cover lives, in order to find new opportunities to spread risk, innovate payment models, and prepare for a transition in value based care.
When patients are diagnosed with cancer, a lot of times the first inclination is to find a Designated National Cancer Institute Accredited Cancer Program. In layman’s terms: I want to go to the best place for cancer care, and Academic Medical Center. This is the likes of MD Anderson, Memorial Sloan, Fox Chase, Mayo, The Ohio State University. This is understandable. When it comes to cancer, you want to make sure you have access to the best treatments available, to cure you or your loved one, and to give you best chance at beating cancer.
However, it is also important for us to understand that seeking care at an Academic Medical Center also impacts the timeliness in which we transition from a diagnosis to beginning treatment.

As the above chart depicts, patients receiving care within an Academic Medical Center will typically experience longer wait times in starting their treatment as compared to those patients receiving treatment at a local community cancer center.
Granted, some of this may be due to a more multidisciplinary team approach at larger Academic Medical Centers. Most large centers, like MD Anderson, will require patients to have all of their labs, imaging studies, reports, and all other pertinent information with them at the time of appointment. If you do not have all of the information, you will most likely not be able to have your appointment. This is not a bad or a good thing, it is just a reality. In order for the multidisciplinary team (MDC) to be able to understand the patient’s diagnosis and to discuss the best option for treatment, they need to have all of the information.
Smaller community centers tend to be a bit more nimble and flexible due to their focus within a community to provide care for cancer patients. In this setting, more times than not, the medical oncologist will be the “quarterback” of a patients care to coordinate all of the testing, imaging, and delivering the treatment options to the patient. Due to this coordination, the medical oncologist can time things accordingly and if they do not have all of the information immediately, it can be obtained easily due to patient living within the community and availability to schedule for additional labs, imaging, or other testing that may be needed.
No matter where one goes to receive their cancer care, time is of the essence. It is not always due to the fact that it is cancer and the longer you wait the worse it will be, as much as it is a patient’s anxiety. Once a patient is told that they have cancer, the ticking of a clock goes off internally. I have spent over 13 years speaking, working, and delivering cancer care to patients and communities all over the US, and one of the top 2 items on every patients list is always something referring back to time.
As healthcare professionals, we need to remember this fact. We need to work together in a coordinated, focused, and collaborative effort to ensure that the patient is involved every step of the way. We need to communicate to patients what is happening next, and if we can’t meet our deadlines that we communicate as to what the barrier(s) are that we are experiencing.
This is also part of the need for someone within the healthcare system that helps to bridge the gap between the physicians and staff and the patient. As the complexity of a healthcare system continues to grow with consolidation and mergers, patients needing to transfer and transition from one clinic to another, or moving to a hospital and then to a cancer center will need someone to help guide them through this journey.
Patients need to focus on their role of making treatment choices, taking their medication, showing up to their appointments, and communicating with their healthcare team. Trying to coordinate the fragmentation is something that healthcare needs to make it easy and simple for patients to perform.
Yet there is also some data that supports the importance of time as well. For example, in early stage node negative breast cancer the optimal time to begin treatment is within 90 days for the best overall survival. The median survival for lung cancer is around 6 months. Yet the median number of days to begin treatment is 35 days. (about 17% of the time a patient has left to live) The preferred time between surgery and radiotherapy (radiation therapy) for head and neck cancer is 6 weeks or less.
So there is science to back up a patient’s own natural drive to be quick, fast, and to expedite being told you have cancer to beginning to treat the cancer.

Some of the factors that contribute to delays in treatment are the following:

• Patients that are diagnosed and go to another facility for treatment will have longer wait times to begin treatment
• Percentage of patients waiting initial treatment > 3o days ranged from about 21% for colorectal cancer to 43% for esophageal
• Additional factors influencing wait times:
  • Age of patients (older patients tended to wait longer)
  • Race (African American and Hispanics tend to wait longer)
  • Stage (stage 1 patients tend to wait longer compared to patients with stage 3 or 4 disease)
  • Facility type (NCI and Veterans Administrative Hospitals have longer wait times than community programs)

The so what’s:
Hospitals:

1. How long does it take you to transition patients from one touch to another
2. As you care for patients across a disease site and healthcare system, how are you performing
3. How do you ensure that patients are informed of what the steps are in seeking care and treatment
4. How timely do you communicate, engage, and collaborate with patients

Patients:

1. How quickly do you want to be seen once you are told you have a suspicious finding?
2. How long are you wanting to wait to have an answer whether you have cancer or not?
3. Do you want to simply know if you have cancer or you do not have cancer, or do you want additional details about type of cancer, treatment, prognosis, and other items?
4. Once you are told you have cancer, how long are you willing to wait to see your oncology team?
5. Once you have met with all of the physicians and professionals that make up your healthcare team, how long do you want to wait before you begin treatment?
6. How much information, communication, and collaboration do you expect to have with your team of healthcare providers?
7. Do you want to be the “owner” of your care, or do you want someone within the healthcare team to “own” your care for you?

I have worked with programs to improve these types of metrics for the patients that they provide cancer care to within their communities. It all varies based on the community a healthcare system serves and the people within that community. Some people and communities want it to be fast but have the medical team own their care; others are willing to wait a bit longer as long as they as people and patients can own their care.
It’s balancing the expectations of the community and people, patients, and families that seek cancer care with the healthcare system ability to provide that care appropriately and safely.
My own perspective and best practice: 3 days from diagnosis to treatment plan or less.
After all, cancer is a story that no one ever wants to have to dedicate a chapter of their life to write. So why not do all we can to provide the paper and tools to patients so that they can write the story as quickly as possible, turn the page, and begin a new chapter. A fresh chapter that is free of cancer.
As always, you can feel free to contact me at: CANCERGEEK@GMAIL.COM
~CancerGeek
#PtExp #PX #cancer #hcldr #hccosts #hcsm
Informational Resources:

• Allison P. Logistic Regression Using SAS: Theory and Application. Cary, NC: SAS Institute Inc; 1999.
• Ashing-Giwa K, Gonzalez P, et al. Diagnostic and Therapeutic Delays Among a Multiethnic Sample of Breast and Cervical Cancer Survivors, 2010. Cancer 2010;116:3195–204.
• Billmoria Karl, Ko Clifford, et al. Wait Times for Cancer Surgery in the United States, 2011. Annals of Surgery. 2011;253(4):779-785
• Fedwa S, Ward E, et al. Delays in Adjuvant Chemotherapy Treatment Among Patients With Breast Cancer Are More Likely in African American and Hispanic Populations: A National Cohort Study 2004-2006. J Clin Oncol 28:4135-4141.
• Lobb R, Allen J, et al. Timely Care After an Abnormal Mammogram Among Low-Income Women in a Public Breast Cancer Screening Program. Arch Intern Med. 2010;170(6):521-528