Time to Treat is Increasing, Associated with Worsened Survival

Cleveland Clinic study of 3.7 million patients

After reviewing nearly 3.7 million patient records, Cleveland Clinic researchers have shown that an increase in time-to-treatment (TTT) initiation for new cancer diagnoses adversely affects outcomes. The team studied trends in TTT for common solid tumors treated with curative intent, determinants of delayed TTT and impact on overall survival. They found that TTT has lengthened significantly in recent years.

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Researchers utilized population-based, prospective data from the National Cancer Database for newly diagnosed U.S. patients with certain early-stage solid-tumor cancers from 2004 to 2013. TTT was defined as days between diagnosis of cancer and first treatment (surgery, systemic or radiation therapy). The study was accepted for presentation at the 2017 American Society of Clinical Oncology (ASCO) Annual Meeting in Chicago and published in PLoS One. 

The study population of 3,672,561 patients included those who had breast, prostate, colorectal, non-small cell lung (NSCLC), renal and pancreatic cancers. Median TTT increased from 21 days in 2004 to 29 days in 2013. Determinants of delays included care at academic centers and change in treating facility. Increased TTT was associated with worsened overall survival (OS) for stages I and II breast, lung, renal and pancreas cancers, and stage II colorectal cancers, with an increased mortality of 1.2 to 3.2 percent per week of delay, adjusting for comorbidities and other variables.

Prolonged TTT of greater than six weeks was associated with substantially worsened OS. Five-year OS for stage I NSCLC was 56 percent for TTT of less than or equal to six weeks, versus 43 percent for TTT greater than six weeks. Stage I pancreatic cancer was 38 percent versus 29 percent, respectively.

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“In addition to its impact on outcomes, delayed TTT can cause unnecessary stress and anxiety for patients,” said Brian Bolwell, MD, Chairman of Cleveland Clinic Cancer Center and senior author of the research. “Coordinating care is difficult, particularly in academic cancer centers, but once you take the time to identify all the hurdles and address each of them, progress in TTT is achievable.”

Cleveland Clinic cancer programs have made reducing TTT for cancer patients a priority, an effort that began in 2014. Overall TTT initially was similar to that of other major cancer centers. It decreased 17.5 percent by mid-2017 and 33 percent by 2018, with Cleveland Clinic’s largest cancer programs (breast, colorectal and lung) showing the greatest reduction. The organization’s goal is to reduce TTT further, to less than 20 days.

“Physicians need to commit to multidisciplinary care and form integrated practice units that focus on patients,” said Alok A. Khorana, MD, Director of Cleveland Clinic Cancer Center’s Gastrointestinal Cancer Program and the study’s first author. “TTT needs to be measured and emphasized, and we must understand what is important to each individual patient and not assume we already know.”