Background: Lung cancer is a public health problem in Morocco. Multiple clinical practice guidelines recommend rapid evaluation of patients with suspected lung cancer. It is uncertain whether delays in diagnosis and management are correlated with outcomes. The objective of this study was to evaluate if these delays have any negative effect on outcomes. Methods: This retrospective study included 140 patients diagnosed with non-small cell lung cancer (NSCLC). It was conducted at the Medical Oncology Department of Fez from January 2016 to December 2017. We have studied many wait times and considered that: wait time to consult (WTC) is the delay from the first symptom to initial consultation, wait time to diagnosis (WTD) is the delay from initial consultation to diagnosis, wait time to referral (WTR) is the delay from diagnosis to referral to the oncologist, and wait time to treatment (WTT) is the time from referral to treatment initiation. Our analysis used Kaplan–Meier method to estimate the overall survival (OS). To compare the OS between wait time categories, we used the logrank test. Results: The median age was 59.46 years. The sex ratio was 6 men for 1 woman. The most common histological subtype was adenocarcinoma (58.6% of cases). Eighty-two percent of patients were diagnosed at stage IV. The median WTC was 240 days (range, 15–280 days), WTD was 45 days (13–65), WTR was 54 days (13–63), and WTT was 32 days (12–40). The only factor that was associated with a long WTD was long distance (> 60 km) to the hospital (p = 0.05). We found that short WTC, WTD, and WTR had better OS: 12 versus 3 months (p < 0.0001), 12 versus 4 months (p < 0.0001), and 14 versus 5 months (p < 0.0001), respectively. We found no difference in OS between short and long WTT. Conclusion: In our study, patients with lung cancer experience significant delays from development of symptoms to first treatment initiation. We found a clear association between survival and short delays from initial symptoms to consultation, from consultation to diagnosis, and from diagnosis to referral to the department of oncology.
Lung cancer is a public health problem in the world. In Morocco, according to the Metropolitan Casablanca Region's Register, lung cancer constitutes the leading cause of cancer in men. More than 70% of cases are diagnosed with stages III and IV. Thus, survival rate among this population remains poor, emphasizing the need to start a treatment as soon as possible.
Wait time to diagnosis (WTD) and wait time to treatment (WTT) are a concern, especially in localized disease as any delay may cause an increase in the tumor volume and infiltration leading to the staging modification and a prognosis worsening. A previous study has shown that the mean doubling time of lung cancer is 166.3 days. Besides, several studies have concluded an association between long wait times before treatment and poorer outcomes. The majority of these studies have been interested in localized disease. Data of correlation between long-time spans and diagnosis or treatment in advanced lung cancer are lacking.
The objective of this study was to evaluate the waiting times to advanced lung cancer specialized consultation, diagnosis, and referral to oncology and treatment initiation. Another objective of this study was to evaluate if these delays have any negative effect on outcomes.
Materials and Methods
Clinical context and study design
At the Department of Medical Oncology of Hassan II University Hospital, a public academic hospital in Fez, Morrocco, almost 2000 new cases are recorded each year. Lung cancer represents 10% of all these cancers among which advanced non-small cell lung cancer (NSCLC) represents 60% of diagnosed cases.
In this retrospective cohort study, we included all patients diagnosed with metastatic NSCLC who were treated in the Medical Oncology Department of Hassan II University Hospital of Fez from January 2016 to December 2017. We excluded patients with unavailable medical records. The majority of these patients had consulted the general practitioner for chest pain or other respiratory symptoms. After this first consultation, the patients were referred to pneumologists who performed a chest computed tomography (CT) scan and bronchoscopy with histological examination leading to the lung cancer diagnosis. The cases were then discussed with the cerebral and thoracoabdominopelvic CT scan in the thoracic tumor board meeting. Thereafter, the patients were referred to the medical oncology department. A pretherapeutic workup was then performed before the initiation of systemic treatment. The process mapping to referral of cases with lung cancer is illustrated in Figure 1.
Data extraction and outcome definitions
Patient medical records were consulted for the following information: age, sex, literacy status, marital status, distance from home to hospital, smoking status, histological subtype, lung cancer symptoms (mainly: pain, hemoptysis, cough, and dyspnea), presence of cerebral metastases, date of initial consultation in the pneumology department, date of histological confirmation of lung cancer, date of referral to the medical oncology department, date of systemic treatment initiation, response to treatment, and dates of disease progression and death.
We defined four categories of wait times. First, the wait time to consult (WTC) is the wait time from the first symptom to the initial consultation of the general practitioner. The second is WTD, which is time from the initial consultation of the general practitioner to diagnosis conducted by the pneumologist. The third is wait time to referral (WTR), which is time from diagnosis to referral to the oncologist, and the fourth is WTT, which is the time from referral to treatment initiation. The overall survival (OS) was measured from the time of diagnosis to the date of death or the date of the patient last seen.
Our analysis used Kaplan–Meier method to estimate the OS. To compare the OS between wait time categories we used the logrank test. A time interval more than 6 months was chosen to define a long WTC, and a time interval more than 30 days was considered for other waiting times. We also performed a root-cause analysis. We analyzed the association between longer wait times and the following factors: age older than 75 years, female gender, illiteracy, single status, distance from home to hospital more than 60 km, smoking status, respiratory symptoms, and neurological symptoms. Data were analyzed using SPSS software (version 20.0, IBM Corp., Armonk, NY: IBM Corp).
In our study, we included 140 patients, and the median age of the patients was 59.46 years (range, 33–86 years). The sex ratio was 6 men for 1 woman. The patients were mostly married (95%). Seventy-five percent of patients in our study were illiterate. More than half of the patients (52.7%) were living within 60 km of the hospital, whereas 12.4% lived beyond 300 km. The majority of patients (79.8%) were previous or current smokers. The most common symptoms at presentation were chest pain (32.5%), dyspnea (32.5%), hemoptysis (27%), and cough (6%). A total of 2.5% patients reported neurological symptoms before diagnosis. The most common histological subtype was adenocarcinoma (58.6% of cases). Eighty-two percent of patients were diagnosed at stage IV and 94.3% of our patients received systemic therapy.
The median WTC was 240 days (range, 15–280 days), and 75% of patients waited more than 6 months.
The median WTD was 45 days (13–65), and 70% of patients waited more than 30 days.
The median WTR was 54 days (13–63), and 70% of patients waited more than 30 days.
The median WTT was 32 days (12–40), and 26.42% of patients waited more than 30 days.
Root cause analysis
The only factor that was associated with a long WTD was the long distance to the hospital (p = 0.05). None of the studied factors was associated with long WTC or WTR. Likewise, none of the factors had a statistically significant association with long WTT. However, a tendency to shorter WTT was observed in patients with cerebral metastases (p = 0.06).
A WTC less than 6 months had a better OS than a long WTC, with median 12 months versus 3 months (p < 0.0001) [Figure 2]. Likewise, a WTD less than 30 days had a better OS than a long WTD, with median 12 months versus 4 months (p < 0.0001) [Figure 3]. A WTR less than 30 days had a better OS than a long WTR, with median 14 months versus 5 months (p < 0.0001) [Figure 4]. On the contrary, the long WTT did not affect the OS (p = 0.08) [Figure 5].
The study revealed long waiting times for patients with advanced NSCLC in our institution. The observed median WTC (240 days) was much longer than is recommended. This delay may be due to illiteracy and nonspecific symptoms of lung cancer that may be confounded with other diseases. Actually, patients tend to seek help late, failing to recognize that their symptoms are sufficiently severe to warrant consulting a doctor.
The median WTD in this study (45 days) was higher than the target (30 days). Diagnosis of lung cancer requires use of bronchoscopy, imaging mainly cerebro-thoracoabdominopelvic CT scan and pathological examination. The number of new cancer cases increases constantly in Morocco and overcomes the hospital's capacities to respond to the population needs. To overcome this, the hospital budgets should be increased. A little incentive for medical staff to increase production may be helpful.
The median WTR (54 days) was also higher than the target (30 days) in this study. None of the studied factors were associated with a long WTR. This delay may be minimized by involving oncologists earlier in the chain of management through case discussions in the tumor board meetings.
The median WTT (32 days) observed in this study was comparable with the target (30 days). This delay may be due to the time needed to perform pretherapeutic assessment (biological workup and cardiac assessment). In addition, specific stresses were seen in treatment resources (number of oncology specialists, inpatient and outpatient beds, etc.). We also found a tendency of association between cerebral metastases and short median WTT. This finding probably indicates that patients with cerebral metastases receive treatment more promptly because of the severity of their neurological symptoms.
Another crucial result of this study indicates that longer delay times from the initial symptom to consultation, from consultation to diagnosis, and from diagnosis to referral to the oncological department were associated with a poorer prognosis. However, no association was found between delay time from referral to treatment initiation and overall survival. In this study, only one-quarter of patients had a WTT more than 30 days, whereas the median WTT of the whole series was 32 days. We think that the difference in median WTT for patients having short versus long WTT was small. This difference was unable to identify an effect of WTT on clinical outcomes in advanced lung cancer. Although our study did not show a significant effect of shorter WTT on survival, we still believe that shorter WTT has a positive effect with respect to patient anxiety, quality of life, and may influence the treatment decision because of performance of status deterioration.
This is one of the few studies that has assessed separately the influence of each waiting time on survival, but our study has limitations. One weakness is that the data were obtained retrospectively from patients' records. The date regarding first contact to the general practitioner with suspicion of cancer may be less precise than the other key dates, as it was often secondhand information. Besides, we were not able to identify all the variables that could have led to increased wait times, such as patient's choice and access to transportation. Finally, data about patient quality of life and satisfaction were also lacking.
To reduce waiting times, we suggest the following:
Raise awareness in the Moroccan population about the interest of consulting general practitioner for any chronic respiratory symptomatology, whatever its severity.
Raise awareness among Moroccan general practitioners about the importance of performing a chest CT scan for chronic respiratory symptoms.
Sensitize decision-makers on the potential role of regionalizing thoracic cancer care to improve overall outcomes of patients with lung cancer.
Encourage decision-makers to increase the hospital budget allocated to the acquisition of CT and endoscopy equipment and incentivize the hospital physicians to increase their daily production and consequently reduce the delay to perform diagnostic exams.
Increase the number of beds in the oncology day hospital.
Discuss all lung cancer cases in the tumor board meetings.
Patients with lung cancer experience significant delays from the development of symptoms to the first treatment in our institution. These delays may cause an increase in the tumor volume and infiltration, leading to the patient's performance status worsening and limiting the treatment choices. In this retrospective study, we found a clear association between survival and long delays from initial symptoms to consultation, from consultation to diagnosis, and from diagnosis to referral to the department of oncology.
Financial support and sponsorship
The authors disclosed no funding related to this article.
Conflicts of interest
The authors disclosed no conflicts of interest related to this article.
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