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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
Author
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.

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