Article and Video CATEGORIES

Cancer Journey

Search By

Dr. Jack West is a medical oncologist and thoracic oncology specialist, and Executive Director of Employer Services at the City of Hope Comprehensive Cancer Center in Duarte, CA.

The Timeliness Factor: Duration of Work-Up for Lung Cancer
Fri, 09/12/2008 - 15:54
Howard (Jack) West, MD, Associate Clinical Professor, Medical Oncology, Executive Director, Employer Services, Founder, President and CEO of GRACE

One issue that everyone with lung cancer faces, but that we haven't covered before, is the duration of a lung cancer work-up. I've worked in a range of treatment settings and see patients for second opinions who come from very different backgrounds and receive their work-ups through completely different medical systems. In that process, you see some patients who receive a stunningly fast series of tests and a short interval from first suspicious finding to diagnosis and ultimate treatment of cancer. Reading the documentation of someone coming for a second opinion, it pains me a bit to see that someone was first found to have an abnormal x-ray 9 months before their diagnosis, because they were told it was likely nothing, or they were told nothing at all, only to lose 40 pounds before someone realized somthing might really be wrong. On the other hand, it's impressive to see patients who have a brisk workup and initiate treatment rapidly. It's certainly pretty common to have someone get a course or two of antibiotics for a few weeks after an ambiguous chest x-ray before any alarm bells go off, but how long is too long?

A couple of recent studies are now reporting some observations from different health care systems. One comes from the Veteran's Administration (VA) system here in the US, which is the closest our country has to a single payor health care system, which lends itself to collecting a broad array of data from many institutions. The report (abstract here) describes the results from a huge chart review of 2463 patients with newly diagnosed lung cancer in around 2005 from 133 different VA hospitals. They found that there was a median of 72 days from first imaging finding to the start of treatment, with one quarter going out more than four months. There was a trend toward much shorter intervals between first imaging and treatment in patients with advanced (Stage IV) disease, at 48 days, compared with 95 and 98 days for stage I and II, respectively. Stage III patients had a median interval of 69 days before treatment started.

I suspect that these numbers are longer than would be seen in many private systems, since the VA system has some unique barriers for US-based health care, including access to PET or other imaging, "problems in coordination of care" (people's cases falling through the cracks), and delays on the patient side in terms of not getting around to pursuing the work-up, or travel challenges. How did another single payor system do?

A group out of Nova Scotia also reported their findings for lung cancer patients with early stage NSCLC diagnosed in 2005 (abstract here). Starting with 540 patients with a new diagnosis of NSCLC in 2005, they had 108 who underwent curative surgery, of whom 47 were later referred to medical oncology, and only 29 received it (this really shows how different the idealized concept of surgery followed by adjuvant chemo is from the real world experience of real patients with real complications). In this system, the median wait time 107 days between detection and surgery, and there was a median of 52 days between surgery and chemo. We generally target about 5 to 7 weeks, so the latter number isn't far off, but the median wait time of more than 3 months from initial detection to surgery is concerning.

There's really no baseline information out there, so both of these groups that developed and wrote these manuscripts have done a service by highlighting potential shortcomings in their systems in order to initiate questions of how to improve the delays. I can't tell you what the median time line for the work-up of a well-insured new lung cancer patient receiving care at a "typical" private practice setting is now, because there is such an incredible range of patient situations, physician practice styles, and institutional processes, in terms of access to physicians and tests. I wouldn't say that it's wrong to give someone with a lung "infiltrate" a few weeks of antibiotics to see if it improves before sounding an alarm, and it takes weeks for the full work-up of blood tests, CT and PET scans, sometimes lung function tests, seeing a pulmonologist or interventional radiologist to obtain a biopsy, having a pathologist carefully review the diagnosis, then see a surgeon and/or medical oncologist, radiation oncologist, etc., potentially do a mediastinoscopy, etc...(I'm tired of typing and you're tired of reading, but there's often still more that is done before treatment starts). Even a timely, expedited workup is a journey that is likely to take a minimum of 3-4 and likely up to 6 or 8 weeks, just do get through all of the necessary steps, even without anyone dragging their heels and with good access to tests and specialists. And sometimes when we really push, patients can get overwhelmed with test after test after test for three straight weeks -- so there may be an interval that is "too short" for certain patients to be comfortable with, even if we can achieve it (I certainly have some patients who want to consider their options for a while after I present a recommended treatment plan, so clearly there's such a thing as too fast for some).

Still, we need to recognize that in treating cancer, time is a factor. We don't want the cancer to spread while we take months to work up a potentially curative cancer, and we don't want to permit patients to decline too much to benefit from treatments in advanced disease, when our opportunity to treat while a patient is up for it is going to be limited. These studies provide a starting point for discussion and may highlight how systems can be improved.

Next Previous link

Previous PostNext Post

Related Content

Mandarin LCVL
王林医生用普通话讨论重要的肺癌信息。这些信息包括靶向治疗、晚期疾病的症状、循环肿瘤 DNA、治疗方案等。我们鼓励您与社区中说普通话的人分享。 Dr. Lin Wang discusses important lung cancer information in Mandarin. This information includes targeted therapy, symptoms of advanced disease, circulating tumor DNA, treatment options, and more. We encourage you to share this with the Mandarin speakers in your community. To watch the complete Playlist visit:…;  
Tell your story!  Apply now for the Clinical Trials Experiences through Storytelling Program
We are excited to launch our third year of this program; tell your story and help us help others! Apply Online Now!     GRACE Patient Perspectives: Clinical Trials Experiences Storytelling Program Overview  
Blood Cancer OncTalk
Blood Cancer OncTalk was a live presentation that brought together top oncologists to discuss emerging concepts and treatment options in blood cancer. The program was chaired by Dr. Aaron Goodman, with the participation of Dr. Mazie Tsang, Hematologist / Oncologist; Dr. Autumn Jeong, Hematologist / Oncologist; Dr. Shaji Kumar, Hematologist / Oncologist; and Dr. Sridevi Rajeeve, Hematologist / Oncologist.

Forum Discussions

Hi Caregiver and welcome to Grace.  I'm sorry that you need to be here and hope we can help.  Osimertinib has better efficacy than gefitinib (including OS and reaching the brain)...

Hi Bob, Welcome to Grace.  I'm sorry about your sil.  Unfortunately, cancer becomes resistant to TKIs like tagrisso.  Sometimes all of the cancer becomes resistant at once and sometimes just parts...

Hi Kimberly, Welcome to Grace.  I'm sorry you are here and glad you've found us. 


It sounds like a biopsy would be the next step.  I can't speak to what...

Recent Comments

Hi Tammy,  Welome to Grace. …
By JanineT GRACE … on Tue, 05/16/2023 - 13:44
By Tndiuka10 on Fri, 05/12/2023 - 21:13
Hi Caregiver and welcome to…
By JanineT GRACE … on Fri, 05/12/2023 - 14:20
Hi Bob, Welcome to Grace.  I…
By JanineT GRACE … on Tue, 05/02/2023 - 12:29