varied routes of entry into secondary care and delays in the management of lung cancer in new...

ORIGINAL ARTICLE

Varied routes of entry into secondary care and delays in themanagement of lung cancer in New Zealand

Wendy STEVENS,1,2 Graham STEVENS,1,2 John KOLBE3,4 and Brian COX5

1Discipline of Oncology, University of Auckland, 2Department of Oncology and 3Respiratory Services, Auckland Hospital,4Department of Medicine, Faculty of Medical and Health Sciences University of Auckland, Auckland and 5Hugh Adam CancerCenter, University of Otago, Otago, New Zealand

Abstract

Aim: To determine secondary care transit times for lung cancer patients, whether these times conformed tointernational guidelines and the major factors which influenced these times.

Methods: An audit of secondary care management in Auckland-Northland of lung cancer patients diag-nosed in 2004 (565 patients) provided the opportunity to assess entry routes into and transit times insecondary care.

Results: The most common entry route was via the emergency department (ED) (35%, 198 patients),especially for those with metastatic disease (P < 0.0005). The median time from entry to diagnosis was 22days (interquartile range [IQR]: 11; 42) overall, but only 11 days (IQR: 6; 18) when entry occurred via ED.The median time from entry to treatment was 64 days (38; 93); 59 days (36; 87) for palliative treatment and76 days (50; 111) for curative treatment. Initiation of treatment within British Thoracic Society recom-mended times occurred for 41% patients undergoing surgical resection, 36% receiving definitive (56%palliative) radiation therapy and 40% receiving chemotherapy. The factors that influenced transit times inmultivariate analysis included the entry route, the presenting symptoms, the investigations performed, thetumor type, multidisciplinary discussion and Maori ethnicity.

Conclusion: A high proportion of lung cancer patients, especially those treated curatively, were notmanaged within internationally recommended timeframes. Improved access to primary care may facilitateearlier diagnosis and better resource allocation and prioritizing patients in secondary care may improve thetimeliness of treatment for those most likely to benefit from it, thereby improving survival outcomes.

Key words: hospital delay, lung cancer, management, treatment delay.

INTRODUCTION

Lung cancer presents a major health-care challenge inNew Zealand (NZ). It is the leading cause of cancerdeaths with a reported 5-year relative survival of 10.2%(1994–2003).1 This survival rate is considerably worsethan reported rates for some other developed countries,including Australia (14%; 1992–1997)2 and the USA(15.5%; 1996–2003).3

While high mortality from lung cancer is largelyattributed to the presentation of lung cancer patientswith locally advanced or metastatic disease that pre-cludes curative treatment,4 delays in management arealso believed to contribute to poor survival outcomes.5–9

In NZ, as elsewhere, delays for oncology services (par-ticularly radiation therapy and chemotherapy) havebeen common, as available resources are inadequate formeeting the demand.10–13 It is considered that improvedlung cancer survival requires timely access to specia-list oncology services, consistent with internationalguidelines.8,10

The study aimed to document entry routes into andtransit along the secondary care pathway for lung cancer

Correspondence: Dr Wendy Stevens, Discipline of Oncology,University of Auckland, Building 503, 85 Park Rd, Grafton,Auckland, New Zealand. Email: [email protected]

Accepted for publication 12 March 2008.

Asia–Pacific Journal of Clinical Oncology 2008; 4: 98–106 doi:10.1111/j.1743-7563.2008.00158.x

© 2008 The AuthorsJournal Compilation © Blackwell Publishing Asia Pty Ltd

mailto:[email protected]

patients. Specifically, transit times from entry to second-ary care to diagnosis (the hospital component ofdiagnostic delay), and from diagnosis to treatment(treatment delay) were assessed. While acceptable or“safe” waiting times for lung cancer treatment have notbeen established,11,12 the British Thoracic Society (BTS)has recommended maximum waiting times that are rec-ognized and used internationally.12 Transit times alongthe pathway were compared with these BTS recommen-dations.14 Major factors associated with increased timesto treatment were identified.

METHODS

A retrospective review of all patients diagnosed withlung cancer in 2004 and managed in secondary carein the Auckland-Northland region of NZ was under-taken.15 Auckland-Northland encompasses 1.5 millionpeople (37% of the NZ population in 2004), and isserviced by a single regional oncology service. The studyinvestigated the entry, transit and management of lungcancer patients through secondary care to the initiationof anticancer treatment or until the decision to providesupportive care alone. Approval for the study wasobtained from the Northern Ethics Committee.

Eligibility criteria

Patients were eligible for inclusion if they were diagnosedwith primary lung cancer (ICD-10 33 or 34) during 2004and had some component of initial management insecondary care in the Auckland-Northland region. Asthe study was an audit of secondary care management,patients who were managed entirely in primary care andthose diagnosed post-mortem were excluded.

Patient identification

Patients were identified from regional hospital and oncol-ogy databases, including hospital admissions anddischarges, public and private laboratory databases,surgical databases and private specialist records. Toensure the completeness of the cohort the list of eligiblepatients was compared with a listing obtained from theNZ Cancer Registry (Stevens et al. in press), whichreceives mandatory notification of all malignant diseasediagnosed in NZ. In total, 565 eligible patients wereidentified.

Data collected

Data for eligible patients were accessed from their elec-tronic and paper medical records, and included theirdemographic information, comorbidities, tumor char-

acteristics and details and dates of presentation tosecondary care, referrals, first appointments with res-piratory medicine, cardiothoracic surgery, medicaloncology and radiation oncology, the investigationsperformed, diagnosis, discussion at a multidisciplinarymeeting (MDM), and initial anticancer treatmentreceived (surgical resection, chemotherapy or radiationtherapy). For patients who did not receive anticancertreatment, the date of a decision for supportive care wasrecorded if available.

Entry routes into secondary care were grouped intothe following 7 categories: entry via the emergencydepartment (ED) with or without a general practice (GP)referral, GP referral to a respiratory specialist, GP refer-ral to a specialist service other than a respiratory service,patient already under secondary care for a respiratorycondition when the presentation with lung canceroccurred, patient already under secondary care foranother medical condition, a complex entry routesuch that a subsequent referral or presentation at EDoccurred prior to the initial referral being actioned andreferral from outside of the region. The entry date wasthe date that any secondary care service first becameaware of the patient presenting with symptoms or anabnormality suggesting the possibility of lung cancer.Usually the entry date was the date of receipt of thereferral to secondary care. For patients already undersecondary care the entry date was usually the date anabnormality suggesting lung cancer was noted.

Presenting symptoms were categorized as an inci-dental finding, symptoms suggestive of loco-regionaldisease, symptoms suggestive of metastatic disease, orother (paraneoplastic symptoms). Comorbidities werescored according to the internationally validated Charl-ston comorbidity index (CCI).16,17

The diagnosis date was defined as the date of thepathology report confirming malignancy or, in theabsence of a histological diagnosis, the date of firstdocumentation of a presumptive diagnosis of lungcancer in the clinical records.

Tumor details included the histopathological type andsubtype, the clinical tumor stage at diagnosis and thepathological tumor stage for patients with tumor resec-tion. The stage was assigned by one author (GS) follow-ing a retrospective review of the reports of staginginvestigations. Small cell lung cancer (SCLC) was stagedaccording to the standard definition of limited orextensive disease.18 All other cancers were stagedaccording to the Union Internacional Contra laCancrum/American Joint Committee on Cancer (UICC/AJCC) TNM definitions.18,19

Delays in management of lung cancer in NZ 99


Asia–Pac J Clin Oncol 2008; 4: 98–106

In this study treatment referred only to the initialmanagement following diagnosis. The type of manage-ment was classified as either anticancer treatment orsupportive care. Anticancer treatment implied surgicalexcision or cyto-reduction of the cancer with chemo-therapy or radiation therapy and was delivered witheither a curative or a palliative intent. By contrast, sup-portive care implied symptomatic management withoutactive treatment of the cancer and was always deliveredwith palliative intent.

Delays documented in the clinical notes werecategorized as patient-related, comorbidity-relatedor institution-related and were subdivided into pre-diagnostic or post-diagnostic delays.

Analysis

The analysis was performed using SPSS version 14 (SPPSInc, Chicago, IL, USA, 2005). c2 was used to assessassociations between categorical variables. Logisticregression was used to assess the association betweenfactors and entry into secondary care via ED. Thepatient pathway from entry into secondary care to ini-tiation of treatment was divided into entry to diagnosis,and diagnosis to treatment. Transit times were calcu-lated for the overall pathway, the two sections of thepathway and for various other events in the pathway.Simple and multiple linear regressions were used toassess the association between factors and transit times.Multivariate models included patient factors such astheir age, gender and ethnicity, NZ deprivation index2001 (NZDep)20 and CCI, tumor factors such as tumortype (NSCLC or SCLC), stage, and presenting symp-toms, and institutional factors such as private care, entryroute, respiratory service involvement, number of anti-cancer services involved, investigations performed (com-puted tomography [CT] scan, CT fine needle aspirate(CTFNA), bronchoscopy, initial bronchoscopy non-diagnostic), histological or clinico-radiological diagno-sis, MDM and delays documented in the clinical records(patient-related, comorbidity-related or institution-related delays).

RESULTS

Detailed results concerning the patient, tumor and man-agement characteristics in the study have been presentedin a previous paper.15

Presentation to secondary care

Of the 565 eligible patients, 64% (360 patients) pre-sented with loco-regional, predominantly respiratory

symptoms, 20% (114) presented as an incidentalfinding, 15% (87) presented with symptoms suggestiveof metastatic disease and four patients presented with aparaneoplastic syndrome. Of those presenting as an inci-dental finding 52 (46%) patients were asymptomaticwith an abnormality that was noted on a routineor follow-up chest X-ray (CXR) or CT scan, while theremainder presented with symptoms not directly attrib-uted to the lung cancer (for example, a chest pain due tomyocardial infarction or vague, non-specific symptomssuch as tiredness or a fall).

Initial presentation via ED (either self-referred orGP-referred) was the commonest mode of entry to sec-ondary care (35%; 198 patients). Another 28% (160) ofpatients were referred from a GP to the respiratoryservice, 9% (50) were referred from a GP to a secondaryservice other than a respiratory one, 6% (35) werealready under secondary care for another respiratorycondition or abnormality, 16% (92) were already undersecondary care for a non-respiratory condition, 4% (25)required a further referral (14) or presented at ED (11)prior to the initial referral being actioned, and 1% (five)were referred from outside the region. In total, 209(37%) patients entered secondary care via ED, includingthe 198 patients who initially presented via ED and the11 patients who were initially referred to a secondarycare service but before being seen presented at ED due tothe deterioration of their condition.

The route of entry into secondary care varied accord-ing to the stage of the disease, presenting symptoms andethnicity. Entry via ED was more common for thosewith advanced disease (P < 0.0005). Of those withnon-small cell lung cancer (NSCLC), 45% of stage IVpatients entered via ED compared with 33% of stage IIIand 18% of stage I/II patients. Of those with SCLC,52% with extensive disease entered via ED comparedwith 27% with limited disease. Patients with symptomsfrom lung cancer were more likely to enter via ED thatthose with an incidental finding (P < 0.0005). Pacificpatients were more likely to present via ED than any ofthe other ethnic groups (P = 0.03), 52% of Pacificpatients initially presenting via ED compared with 38%of Maori, 32% of European, and 26% of Asian patients.

After adjusting for age, tumor type and stage inmultivariate analysis, Pacific patients were twice aslikely to present first via ED as Europeans (P = 0.02).After adjusting for age, ethnicity and tumor type,patients with metastatic disease were 3.6 times morelikely (P < 0.005), and those with locally advanceddisease twice as likely (P = 0.02) to present via EDas those with localized disease. Entry via the ED was

100 W Stevens et al.



associated with a reduced median time to diagnosiscompared with the other entry routes (P < 0.001)(Table 1).

Transit times within secondary care

Of the 565 eligible patients, 15 patients were excludedfrom the analysis of transit times from entry to diagno-sis: six patients were diagnosed elsewhere prior to entry,either in another region (three patients) or in primarycare (three) and a date of entry could not be determinedfor nine (<2%) patients. All patients who received anti-cancer treatment were included in the analysis of transittimes to treatment.

The median time from entry to treatment (285patients) was 64 days (interquartile range [IQR]: 38;93). For those who were managed with curative intent(109 patients) the median time was 76 days (IQR: 50;111) and for those managed with palliative intent (176patients) it was 59 days (IQR: 36; 87) (P = 0.03).

Of the 550 patients included in the analysis of transittimes from entry to diagnosis, 64% (354 patients) werediagnosed within 1 month of entry, 85% (46 patients)within 2 months and 93% (511 patients) within 3months of entering secondary care. Of those whoreceived anticancer treatment (285 patients), 49% (139patients) commenced treatment within 1 month of diag-nosis, 82% (234 patients) within 2 months and 93%(265 patients) within 3 months. The transit times forpatients with various characteristics are shown inTable 1.

Increased time from entry to diagnosis was associatedwith decreasing tumor stage, decreasing severity ofsymptoms, entry route other than via ED, the perfor-mance of investigations, MDM discussion and docu-mented patient or institution-related delays.

In multivariate analysis (with age, comorbidity,ethnicity, tumor stage, presenting symptoms, entryroute, CTFNA, CT scan and initial bronchoscopy non-diagnostic and histological diagnosis included in themodel), loco-regional (P = 0.015) or metastatic symp-toms (P = 0.002) rather than an incidental finding, entryroute other than via ED (P < 0.0005), and performanceof investigations (P < 0.0005) were associated withincreased time to diagnosis. Discussion at an MDM wasalso associated with increased time to diagnosis (afteradjusting for the above factors) (P = 0.003). In multi-variate analysis after adjusting for presenting symptoms,entry route and investigations performed, tumor stageno longer had a statistically significant association withincreased time to diagnosis, suggesting that less severesymptoms, entry other than via ED and increased inves-

tigation were responsible for the longer times to diag-nosis for patients with early stage disease.

Increased time from diagnosis to treatment was asso-ciated with increasing age, the presence of comorbidity,Maori ethnicity, NSCLC tumor type, involvement ofmore than one anticancer service, MDM discussion anddocumented delays. In multivariate analysis (adjustingfor age, CCI, NZDep, ethnicity, tumor type and stage,treatment intent): NSCLC tumor type (P < 0.01), Maoriethnicity (P < 0.0005) and age �80 years (P = 0.047)were associated with increased time to treatment. Aftercontrolling for the above factors, discussion at a MDMwas also associated with increased time to treatment(P < 0.0005). Longer times from entry to diagnosistended to be associated with shorter times from diagno-sis to treatment, although this association was ofborderline significance (P = 0.05) after controlling forthe above factors.

In total, 138 delays were documented in the clinicalrecords. Of these, 44 were patient-related, 44institution-related and 50 were associated with comor-bidity. Four patients experienced more than one typeof delay. Patient-related delays occurred throughoutthe pathway and commonly involved their failure toattend or their deferment of appointments or treatment.Patient-related delays increased the median time to diag-nosis (P = 0.004) by 20 days and the median time totreatment (P = 0.002) by 17 days. Institution-relateddelays occurred more commonly before diagnosis andpredominantly involved a delayed follow up of abnor-mal results, referrals lost in the system or prolongedwaiting times for appointments. Institution-relateddelays increased the median time to diagnosis(P < 0.0005) by 41days, and the median time to treat-ment (P = 0.01) by 31 days. Comorbidity did notsignificantly increase the median time to diagnosis(P = 0.10) but was associated with an increased mediantime to treatment (P = 0.04) of 17 days.

Comparison of transit times with BTS

recommended times

The times of various events in the secondary carepathway were compared with those times recommendedby the BTS (Table 2). Only 41% of patients underwentthoracotomy within the recommended 8 weeks fromthe first respiratory consultation, 36% commencedradical radiation therapy within 4 weeks of firstseeing the radiation oncologist and 40% commencedchemotherapy within 7 days of first seeing the medicaloncologist.




Table 1 Transit times from entry into secondary care to diagnosis, and from diagnosis to initiation of treatment

Time from entry to diagnosis Time from diagnosis to treatment

Patients N Median (days) IQR (days) P < 0.05† Patients N Median (days) IQR (days) P < 0.05†

Total 550‡ 22 (11, 42) 285 31 (15; 33)Age

<60 years 116 22 (11, 39) 89 27 (8; 49)60–69 years 160 23 (11, 48) 0.93 98 32 (13; 53) 0.0470–79 years 173 22 (11, 43) 0.78 75 35 (16; 59) 0.05�80 years 101 18 (8, 35) 0.11 23 49 (22; 76) 0.03

GenderMale 304 21 (10, 40) 157 30 (13; 53)Female 246 23 (12, 47) 0.31 128 33 (12; 55) 0.57

EthnicityEuropean 365 22 (11, 42) 199 29 (12; 52)Maori 93 21 (10, 37) 0.64 49 43 (25; 62) 0.002Pacific 56 21 (8, 38) 0.37 18 34 (11; 53) 0.80Asian 23 28 (14, 46) 0.77 12 28 (7; 47) 0.44Other 6 21 (7, 56) 0.67 4 25 (-6; 43) 0.41Unstated 7 19 (10, 32) 0.86 3 36 – 0.68

Tumor typeNSCLC 481 22 (11, 43) 242 36 (15; 55)SCLC 69 16 (9, 28) 0.01 43 17 (10; 28) 0.001

NSCLC§

Stage I/II 140 35 (16, 65) 100 36 (8; 63) 0.56Stage III 127 26 (14, 49) 0.02 61 41 (19; 60) 0.49Stage IV 192 16 (8, 34) <0.0005 78 33 (19; 49) 0.61Stage unknown 22 7 (1, 17) – 3 29 – –

SCLCLimited 25 20 (11, 31) 20 19 (9; 28)Extensive 44 15 (9, 25) 0.48 23 17 (10; 31) 0.80

Entry routeED 198 11 (6, 18) 74 31 (13, 55)Other than via ED 352 30 (16, 57) <0.0005 211 33 (13, 52) 0.45

SymptomsIncidental finding 112 37 (16, 65) n/a n/a n/a n/aLoco-regional 352 22 (10, 39) <0.0005Metastatic/other 86 13 (8, 21) <0.0005

InvestigationsCT chest

No 36 5 (1, 19) n/a n/a n/a n/aYes 514 23 (12, 42) <0.0005

BronchoscopyNo 245 16 (7, 40)Yes 305 27 (14, 43) <0.0005

CTFNANo 415 17 (8, 32)Yes 135 42 (22, 68) <0.0005

Initial bronchoscopy non-diagnosticNo 466 19 (9, 36) n/a n/a n/a n/aYes 84 36 (21, 66) <0.0005

Clinico-radiological diagnosisNo 464 24 (13, 43) n/a n/a n/a n/aYes 86 9 (4, 25) <0.0005

MDMNo 511 20 (10, 40) 195 27 (9; 48)Yes 39 51 (26, 89) <0.0005 90 47 (29; 65) <0.001

Treatment intent††

Curative 109 36 (18, 65) 109 29 (7; 59)Palliative 447 19 (9, 36) <0.0005 176 33 (17; 51) 0.45

†P-values derived from simple linear regression analysis. ‡Fifteen patients were excluded: six were diagnosed elsewhere prior to entering secondarycare in the region and for nine patients the date of entry was missing. §NSCLC: histologically verified, clinico-radiological diagnoses and carcinoidtumors. ††Nine patients were not included in treatment intent: seven patients left the region prior to treatment and two patients on subsequenthistological review did not have lung cancer. n/a, Not applicable. CTFNA, computed tomography fine needle aspirate; ED, emergency department;IQR, interquartile range; MDM, multidisciplinary meeting; NSCLC, non-small cell lung cancer; SCLC, small cell lung cancer.




DISCUSSION

This is the first comprehensive assessment of the timeli-ness of secondary care management of lung cancer inNZ. Timeliness of management is believed to impact onsurvival outcomes and timely access to specialist oncol-ogy services consistent with international guidelines isan objective of the NZ cancer control strategy.8,10 Thecurrent study, however, found that a large proportion ofpatients were not managed within internationally rec-ommended timeframes. It is therefore possible that man-agement delay could contribute to the poor lung cancersurvival outcomes in NZ.

Although several international studies have concludedthat delays did not negatively influence survival11–13,21

other studies have confirmed that there is rapid tumorgrowth with stage migration during waiting timesfor lung cancer treatment.5,6 Delays to diagnosis maydecrease the proportion of patients identified earlyenough in the disease pathway to have potentially cura-tive surgery.7,8,11 Delays while awaiting treatment mayresult in tumor growth that renders potentially curabletumors incurable22 and for those managed curativelydelays may worsen prognosis as the earlier the tumorstage at surgical resection the better the survival.8,12,23

For example, typical 5-year survival rates following sur-gical resection for stage I NSCLC are 50–70%, com-pared with only 35–50% for stage II disease.23 Delaysnot only increase the risk of disease progression but alsoimpact on quality of life and add to the psychologicalstress of patients and their families and are thereforeconsidered unacceptable.8,11,14,24,25

Although the greatest impact of management delayson prognosis and survival is likely to be in those patientswith the possibility of cure, it was patients with more

advanced disease, especially metastatic disease, whocommenced treatment within the shortest times, consis-tent with results from other studies.9,11 Patients withearly stage, potentially curable disease had significantlylonger times from entry to treatment compared withthose with advanced disease. Although the additionaltime required for curative treatment is commonly attrib-uted to the comprehensive pre-operative assessmentrequired for surgical patients8,26 or the complex planningrequired for radical radiation therapy,9 most of the dif-ference in time between curative and palliative antican-cer treatment in the current study occurred betweenentry and diagnosis.

The diagnosis of those with clinically advanceddisease was frequently a simpler process than for thosewith more limited disease. Patients with advanceddisease also more commonly presented with more severesymptoms and entered secondary care via ED than didpotentially curable patients, resulting in rapid in-patientinvestigation, diagnosis and treatment. Such findings areconsistent with international literature6,11,27 which sug-gests there is an association between shorter times totreatment and poorer prognosis, reflecting the prompttreatment of those with severe symptoms.11

The high use of entry via ED associated with severepresenting symptoms, late stage disease and Pacific eth-nicity suggests the possibility of barriers to (or within)primary care. Although financial barriers to primarycare in NZ have been reduced since the introduction ofPrimary Health Organizations and increased govern-ment subsidies other barriers, such as information, cul-tural and geographic barriers, persist. The type ofmedical care sought by patients is believed to be influ-enced by the perceived severity of the illness28 and somepatients believe that the quality of health care is superior

Table 2 Comparison of study times with British Thoracic Society (BTS) recommendations

Pathway events

BTSrecommended

times

Patientswithin BTStimes (%)

The studymedian

time (days)

Receipt of general practitioner referral → first appointment with respiratory 1 week 38 12Receipt of in-patient respiratory referral → first respiratory consultation 2 days 90 1Respiratory consultation → thoracotomy <8 weeks 41 63Receipt of referral by cardiothoracic surgery → thoracotomy <4 weeks 60 21Receipt of referral by radiation oncology → first appointment radiation oncology 1 week 36 12First appointment radiation oncology → Initiation of radiation therapy

Radical treatmentRalliative treatment

<4 weeks 36 30<2 weeks 56 14

Receipt of referral by medical oncology → first appointment medical oncology 1 week 28 14First appointment medical oncology → initiation of chemotherapy 7 working days 40 12




in secondary care than in primary care, and that inves-tigations and treatment are more readily obtainable inthe secondary system.28 There is a need to educate thepublic to encourage earlier presentation to primary careservices and for referral guidelines to ensure appropriateand timely referral of patients with suspected lung can-cer.29 Improved access to primary care services mayreduce delays to diagnosis and the burden on ED andenable better allocation of resources.30,31 Improved com-munication and coordination between primary andsecondary care may also result in the more controlledmanagement of lung cancer and improved standards ofcare.30,31

As the lung cancer pathway involves multiple clini-cians, appointments and investigations12,32 as well asnumerous waiting times, the potential for service gapsand duplication is substantial.32 Appropriate processestherefore are essential to minimize delay. Effective com-munication and coordination between services and theearly involvement of a multidisciplinary team are con-sidered necessary to minimize delays.5,11,12,26,27 In thecurrent study, discussion at a MDM was significantlyassociated with increased times to both diagnosis andtreatment. However, as only 28% of patients were dis-cussed at an MDM this association may have resultedfrom selection bias, especially as most of the patientsdiscussed had early stage NSCLC and were managedsurgically.

Many of the documented institution-related delayswere potentially avoidable. Delay or failure to follow-upan abnormal X-ray or scan was particularly worrying,as this resulted in considerable and perhaps crucial delayfor some patients. Lost referrals indicate systems prob-lems that should be addressed. The identification of suchdelays is a stimulus to review systems to ensure that suchevents are minimized in the future. Clear District HealthBoard processes for dealing with referrals and the followup of abnormal results are required to ensure timelycare.10

In order to achieve the NZ Cancer Control ActionPlan objectives of timely diagnosis and treatment of alllung cancer patients and improved survival outcomes,10

it may be insufficient to simply assign maximum waitingtimes. Clinical management guidelines detailing diag-nostic and treatment processes for lung cancer patientsare required,27 as are guidelines on the stratification ofwaiting lists according to the relative risks in terms oftreatment delay.5 As delays to treatment may worsenprognosis in some patients,8 lung cancer survival couldpotentially be improved by prioritizing (fast-tracking)the patients most likely to be adversely impacted by

delay, that is, those patients most likely to benefit fromprompt treatment.8 Identification of such patientsshould include factors such as tumor type, size andlocation, patient performance status and comorbiditylevel.8

Clinical performance indicators (CPI) to monitorwaiting times, delays and management are required.Transit times could be used as CPI for inclusion incontinuing quality improvement programs. It is, how-ever, insufficient to merely monitor median waitingtimes as these may disguise the substantial delays ex-perienced by some patients, and any quality assuranceprogram should include an assessment of excessivelylong transit times.

This is the first study in NZ to document transit timesin the secondary care pathway and to compare thesewith international recommendations. As the studyencompassed 37% of the population its findings arelikely to be relevant nationally. Although the study didnot assess management prior to entry to secondary care,the high rate of presentation via ED suggests substantialdelay may occur prior to or in primary care. Investiga-tion of such issues is warranted. Retrospective reviewsare limited by the extent and quality of the recordedinformation and it is likely that delays were under-documented in the clinical records. It is of concern thatso many patients failed to attend or deferred appoint-ments and treatment. It was not possible in this retro-spective study to explore the underlying reasons for thisand further evaluation is warranted.

Conclusion

A high proportion of lung cancer patients in the studywere not managed within the timeframes recommendedby international guidelines. Times from entry until treat-ment were longer for patients managed curatively thanfor those treated palliatively, yet it is the former whoare most likely to be disadvantaged by treatmentdelays. Improved access to primary care may result inmore timely and controlled entry to secondary careand permit better resource allocation. Prioritization ofpatients for prompt management in secondary care mayimprove lung cancer outcomes in NZ.

ACKNOWLEDGEMENTS

Funded by a NZ Ministry of Health grant, WS receivedfunding from a University of Otago Postgraduate Awardand the University of Otago Prestigious Scholarship.BC is supported by funds from the Director’s CancerResearch Trust. The authors wish to thank the following




for their assistance and support in data collection: DrAndy Veale, Respiratory Physician, Middlemore Hospi-tal, Dr Martin Phillips, Respiratory Physician, NorthShore Hospital, Dr Mark Kennedy, General Physician,Whangarei Base Hospital, Mr Chris Lewis, NZ HealthInformation Service.

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