Patients with colorectal cancer or non–small cell lung cancer who were treated in the outpatient setting and were not admitted 30 days prior to diagnosis experienced a statistically significant increase in delay of time to treatment initiation.
Along with demographic and socioeconomic disparities, care coordination, clinical, and socioeconomic factors are potential factors for delays in time-to-treatment initiation (TTI), according to findings from a retrospective cohort study published in JCO Oncology Practice.
Findings from the study demonstrated that patients with colorectal cancer (CRC; n = 507) and non–small cell lung cancer (NSCLC; n = 412) who were treated in the outpatient setting and were not admitted 30 days prior to diagnosis experienced a statistically significant increase in delay of TTI, with respective odds ratios (ORs) of 2.82 (95% CI, 1.71-4.66) and 2.11 (95% CI, 1.31-3.39). Additionally, higher Charlson Comorbidity Index (CCI) scores were associated with delayed TTI in patients with head and neck cancer (HNC; n = 296; OR, 2.63; 95% CI, 1.04-6.66) and NSCLC (OR, 1.75; 95% CI, 1.14-2.71).
Among all patients (n = 2543), the median TTI was 25 days (interquartile range [IQR], 6-44). Patients experienced median TTIs of 35 days (IQR, 12.5-51) for breast cancer, 16 days (IQR, 6-40) for CRC, 32 days (IQR, 15-45) for HNC, 20 days (IQR, 7-39) for NSCLC, and 15.5 days (IQR, 5-29) for pancreatic cancer. The median TTIs for patients who were treated with radiotherapy, chemoradiotherapy, and surgery were 36 days (IQR, 24.5-52), 42 days (IQR, 29-58), and 36 days (IQR, 25-48), respectively.
To conduct the study, investigators performed a retrospective review of patients treated with curative-intent radiotherapy, chemoradiotherapy, or surgery with or without adjuvant chemotherapy/radiotherapy/chemoradiotherapy for primary breast cancer (n = 1120), CRC, HNC, NSCLC, and pancreatic cancer (n = 208) from January 1, 2019, to December 31, 2021, at Albert Einstein College of Medicine, in Bronx, New York. Exclusion criteria included age below 18 years at the time of diagnosis, presentation with a diagnosis and/or treatment of recurrent disease within 5 years of primary and second primary cancers, and initial referral for diagnosis or palliative treatment of advanced unresectable/metastatic cancer.
TTI, which was the primary outcome of the study, was defined as time from histopathologic diagnosis to initiation of the first treatment measured in days. Dates of histopathologic diagnosis were obtained from the Montefiore cancer registry, and billing data were used to determine treatment dates. Patients were stratified based on TTI (< 30 days vs ≥ 30 days) and cancer type.
The mean age of the overall population was 63.4 years (standard deviation [SD], +/- 13.4). Most patients were female (69%), had public insurance (58.2%), spoke English (76.9%), and had an unknown AJCC pathologic stage (56.8%). The mean CCI score was 1.1 (SD, +/- 0.4), 18.6% of patients experienced inpatient admission 30 days prior to diagnosis, and most patients had a primary care provider on file (81.8%). Baseline characteristics were generally similar across all cancer types examined.
Most patients had a TTI of less than 30 days (57.6%) and the remaining 42.4% had a TTI of at least 30 days. Comparing these 2 groups, there was no significant difference in race/ethnicity, marital status, CCI score, smoking status, insurance type, PCP status, or emergency department visit in the 30 days before diagnosis. However, patients with a TTI of at least 30 days were found to be younger at the time of diagnosis (mean, 61.6 years vs 64.7 years; P < .001), were more likely female (mean, 75.2% vs 64.4%; P < .001), had a lower median household income (mean, $51,200 vs $53,500; P = .036), and more often chose Spanish as their preferred language (20.5% vs 15.6%; P = .01).
Additionally, patients with a TTI of at least 30 days were more likely to have early-stage disease by AJCC clinical (54.5% vs 37.5%; P < .001) and pathologic staging (43.3% vs 22.5%; P < .001). Patients with a TTI of less than 30 days were more likely to have an inpatient admission 30 days before diagnosis compared with those with a TTI of 30 days or more (24.6% vs 10.3%; P < .001).
A multiple regression analysis of the overall population showed that no inpatient admission 30 days before diagnosis (OR, 2.68; 95% CI, 2.07-3.47), speaking Spanish vs English (OR, 1.51; 95% CI, 1.17-1.95), and CCI score (OR, 1.23; 95% CI, 1.001-1.51) were all associated with a TTI of at least 30 days. Notably, gender (OR, 0.75; 95% CI, 0.61-0.91), late- vs early-stage disease (OR, 0.79; 95% CI, 0.64-0.98), and age (0.98; 95% CI, 0.98-0.99) were associated with less risk of having a TTI of 30 days or more.
Specifically in breast cancer, having Spanish as a preferred language vs English was associated with a greater incidence of TTI being 30 days or more (OR, 1.79; 95% CI, 1.21-2.67; P = .004). Other factors found to contribute to a TTI of 30 days or more included being a former vs never smoker in NSCLC (OR, 2.1; 95% CI, 1.05-4.22), and being a male vs female patient with pancreatic cancer (OR, 1.26; 95% CI, 0.62-2.6).
In HNC, a higher median household income by zip code was associated with less risk of delay (OR, 0.99; 95% CI, 0.98-0.999; P = .039). For all other cancer types, median household income data was not collected or did not have a significant impact on TTI.
Investigators noted that their study was limited by its retrospective nature, the unknown race/ethnicity of a portion of the sample (21%), only examining a single center, and the 30-day threshold used to dichotomize TTI for all cancer types. They contended that future studies should evaluate the services, diagnostics, and consults used in the 30 days preceding diagnosis.
“Our data support evidence that delays in cancer TTI are associated with sociodemographic and socioeconomic disparities. Existing health care disparities are likely exacerbated by these delays in TTI that disproportionately affect patients with gaps in access to care, multiple medical comorbidities, and lower socioeconomic status. A thorough understanding of these disparities may be leveraged to address health care inequalities. The findings described here may serve as an actionable target for improving survival outcomes and inequalities in cancer care,” they wrote in summation.
Sheni R, Qin J, Viswanathan S, et al. Predictive factors for cancer treatment delay in a racially diverse and socioeconomically disadvantaged urban population. JCO Oncol Pract. 2023;19(6):e904-e915. doi:10.1200/OP.22.00779