What's the magic number? Impact of time to initiation of treatment for rectal cancer

Effect of Rectal Cancer Treatment Timing Standardization on Patient Outcomes

OBJECTIVES

The National Accreditation Program for Rectal Cancer (NAPRC) was established in 2017 to decrease rectal cancer treatment variation and improve oncologic outcomes. Initiating curative intent treatment <60 days of first evaluation is one NAPRC standard. We evaluated whether oncologic outcomes improved with timely treatment and factors associated with its receipt.

METHODS

Using the NCDB, we identified stage I to III rectal cancer patients treated from 2004 to 2020 treated with curative-intent surgery. Patients were stratified into 2 cohorts (timely [<60 d], delayed [≥60 d]) for survival analysis and exploration of variables associated with timely treatment.

RESULTS

We included 117,459 patients with a median age of 61 years (interquartile range: 52 to 70 y). Most patients were male (61.1%), White (86.2%), Charlson 0 (77.1%) with stage II (33.5%) or III (44.3%) cancer treated with chemoradiation (58.1%), or surgery (27.0%) first. Timely treatment was associated with improved overall survival (OS; median OS: 153.26 vs. 128.59 m). Patients in the highest income bracket (odds ratio [OR] 1.30) with stage II (OR: 1.27) or III (OR: 1.50) cancer receiving neoadjuvant chemotherapy (OR: 2.24) or chemoradiation (OR: 1.73) as the first treatment received more timely treatment. Patients with Charlson ≥2 (OR: 0.83) of Black (OR: 0.56) or Hispanic (OR: 0.73) race received more delayed treatment (all P <0.01).

CONCLUSIONS

Timely rectal cancer treatment is associated with improved survival. Socioeconomic disparities limit timely treatment with attendant worse survival, supporting national homogenization of care. As multimodal care for rectal cancer becomes increasingly complex, timely treatment remains paramount.

No detectable impact of short-term treatment delays on lung cancer survival

Timely initiation of treatment is a core principle of oncologic care, especially for aggressive cancers such as lung cancer. However, the real-world impact of short-term delays in treatment initiation on survival outcomes in lung cancer remains unclear. This meta-analysis evaluates the association between treatment delays of 4, 8, and 12 weeks and all-cause mortality in lung cancer patients. A systematic search was conducted in PubMed, Scopus, and Web of Science for studies published between 2000 and 2025. Of 5360 screened records, 15 studies were included, comprising 16 cohorts for overall survival of lung cancer patients. Hazard ratios (HRs) for 4-, 8-, and 12-week treatment delays were estimated using random-effects meta-analyses. Heterogeneity was measured with the I2 statistic, and publication bias was assessed using funnel plots and Egger's test. No significant association was found between treatment delay and survival at any of the time points. Pooled HRs were 1.00 (95% CI, 0.99-1.02) for a 4-week delay, 1.01 (95% CI, 0.99-1.03) for an 8-week delay, and 1.01 (95% CI, 0.98-1.05) for a 12-week delay. Despite high heterogeneity (I2 = 97%), no evidence of publication bias was detected. This meta-analysis found no significant impact of short-term treatment delays (up to 12 weeks) on mortality in lung cancer patients. These findings challenge the assumption that brief delays universally worsen outcomes and underscore the importance of individualized treatment planning and prioritization.

Treatment delay significantly increases mortality in colorectal cancer: a meta-analysis

Delaying the initiation of cancer treatment increases the risk of mortality, particularly in colorectal cancer (CRC), which is among the most common and deadliest malignancies. This study aims to explore the impact of treatment delays on mortality in CRC. A systematic literature search was conducted in PubMed, Web of Science, and Scopus for studies published between 2000 and 2025. Meta-analyses were performed using random-effects models with inverse variance method to calculate hazard ratios (HRs) for both overall and cancer-specific survival at 4-, 8-, and 12-week treatment delay intervals, with heterogeneity assessed through I2-statistics and publication bias evaluated using funnel plots and Egger's test. A total of 20 relevant studies were included in the meta-analysis. The analyses of all patients demonstrated a progressively increasing risk of 12-39% with longer treatment delays (4 weeks, HR = 1.12; 95% CI, 1.08-1.16; 8 weeks, HR = 1.24; 95% CI, 1.16-1.34; 12 weeks, HR = 1.39; 95% CI, 1.25-1.55). In particular, incrementally higher hazard ratios were observed for all-cause mortality at 4 weeks (HR = 1.14; 95% CI, 1.09-1.18), 8 weeks (HR = 1.29; 95% CI, 1.20-1.39), and 12 weeks (HR = 1.47; 95% CI, 1.31-1.64). In contrast, cancer-specific survival analysis showed a similar trend but did not reach statistical significance (4 weeks, HR = 1.07; 95% CI, 0.98-1.18; 8 weeks, HR = 1.15; 95% CI, 0.95-1.39; 12 weeks, HR = 1.23; 95% CI, 0.93-1.63). Treatment delays in colorectal cancer patients were associated with progressively worsening overall survival, with each 4-week delay increment leading to a substantially higher mortality risk. This study suggests that timely treatment initiation should be prioritized in clinical practice, as these efforts can lead to substantial improvements in survival rates.

Time to definitive treatment in rectal cancer care coordination

INTRODUCTION

Timely initiation of rectal cancer treatment improves outcomes, and standard of care is to receive definitive treatment within 60 days of diagnosis.

METHODS

A retrospective review of rectal cancer patients (2013-2023) at a tertiary cancer center was performed. Statistical analysis was conducted on patients stratified to time-to-treatment within 60 days and patient sociodemographics.

RESULTS

182/342 (53.2 ​%) rectal cancer patients had time-to-treatment ≤60 days. Unified care was significantly faster than fragmented care (57.5 vs 77.4 days, p ​= ​0.002). Factors associated with time-to-treatment >60 days: sex (p ​= ​0.03), age (p ​= ​0.004), insurance (p ​= ​0.006), Healthy Places Index quintile (p ​= ​0.02), distance from hospital (p ​= ​0.01). Multivariable analysis associated delays with females (OR 1.74 [95 ​% CI 1.05-2.91],p ​= ​0.03), and living >60 miles from the hospital (60-100 miles OR 2.49 [95 ​% CI 1.09-5.85],p ​= ​0.03; >100 miles OR 2.87 [95 ​% CI 1.05-8.25],p ​= ​0.04).

CONCLUSION

In this study, 46.8 ​% of rectal cancer patients initiated definitive treatment >60 days from diagnosis. Unified care improved time-to-treatment. Female sex and living >60 miles from the hospital were associated with delays.

Risk Model for Predicting Gaps in Surgical Oncology Care Among Patients With Stage I-III Rectal Cancer From KwaZulu-Natal, South Africa

PURPOSE

Gaps in surgical oncology care (GISOC), including delayed or nonreceipt of surgery, are detrimental to cancer control. This research sought to develop a risk model for predicting GISOC in South African rectal cancer (RC) patients with localized disease.

METHODS

This retrospective cohort study analyzed data from an existing colorectal cancer patient registry. GISOC was defined as surgery received >62 days after diagnosis with stage I-III RC or nonreceipt of surgery for stage I-III RC. Patient demographics, comorbidity, disease staging, and neoadjuvant therapy receipt were included as covariates in the analysis. A supervised logistic regression machine learning algorithm was used to train and test an appropriate risk model, which was translated into a nomogram. Receiver operating characteristic curve analyses and AUC assessments were used to establish the nomogram's performance.

RESULTS

The analysis included 490 patients (training data set = 245, testing data set = 245). Overall, there were 242 patients who experienced GISOC (49.4%), of whom 33 (13.6%) did not receive surgery and 209 (86.4%) had a delay in receiving surgery. The trained risk model consisted of patient race (Indian, odds ratio [OR] = 0.24; White, OR = 0.23; v Black), comorbidity (OR = 2.29 v no comorbidity), and neoadjuvant therapy receipt (OR = 18.40 v nonreceipt). AUCs for the risk model were >0.800.

CONCLUSION

An accurate, setting-specific risk model and nomogram was developed for predicting GISOC in patients with RC. The nomogram can be implemented without the use of technology to identify patients at high risk for GISOC, who can then be targeted with risk-reduction interventions. The impact of the nomogram on existing surgical unit workflows requires further investigation.

NCCN guideline concordance in colon and rectal cancer patients within a comprehensive health system

BACKGROUND

The National Comprehensive Cancer Care Network (NCCN) provides recommendations for patients with colorectal cancer. Concordance with evidence-based guidelines improves outcomes. Our objectives were to 1) examine rates of guideline non-concordance in a large vertically integrated health system; 2) examine factors associated with non-concordant care, and 3) identify geographical patterns of non-concordant care.

METHODS

Colorectal cancer patients were identified from a single-state 16 hospital health-system cancer registry diagnosed between 2011 and 2021. We defined major (MAJ) and minor (MIN) quality indicators of guideline-concordance based on NCCN guidelines. Regression methods were used to identify predictors of major quality criteria non-concordance. County-level mapping was used to identify geographical locations of the highest rates of non-concordance.

RESULTS

Overall, 2324 patients with colon and rectal cancer were analyzed. There was a complete guideline concordance (an absence of guideline non-concordance) rate of 24.7​% (n ​= ​573), MIN only guideline non-concordance rate of 63.3​% (n ​= ​1471), and MAJ non-concordance rate of 12.4​% (n ​= ​280). Predictors of MAJ non-concordance for colon cancer were stage, >1 Charleson-Deyo Score, >60 days from diagnosis to treatment, and >1 hospital network used for care. Predictors of MAJ non-concordance for rectal cancer were >60 days from diagnosis to treatment, and >1 facility used for care. Marion county had the highest rates of non-concordance for colon and rectal cancer.

CONCLUSION

The majority of colon and rectal cancer patients in a large health system received guideline concordant major quality indicators, however 12​% of patients do not. An identifiable geographical location with the highest rates of non-concordance and its associated factors serves as a target for future quality improvement.

Predictors and outcomes of delays between diagnosis and definitive surgery for rectal cancer

BACKGROUND

The National Accreditation Program for Rectal Cancer (NAPRC) recommends definitive treatment of rectal cancer commence within 60 days from diagnosis. This study aimed to assess predictors of >60 days delay between diagnosis and definitive surgery of rectal cancer and the impact on survival and short-term outcomes.

METHODS

Retrospective cohort analysis of patients with stage I-III rectal adenocarcinoma who underwent proctectomy without preoperative neoadjuvant treatment from the National Cancer Database (2015-2019). Based on the time interval between diagnosis and definitive surgery, patients were divided into timely non-adherent (>60 days) and timely-adherent (≤60 days) groups. Multivariate analysis determined predictors of delayed definitive surgery.

RESULTS

9479 patients (57.5 % males; mean age: 63.7 years) had a 41-day median time between diagnosis and definitive surgery. Non-adherence was noted in 27.9 % of patients. Independent predictors of non-adherence were male sex (Odds ratio [OR]: 1.25; p < 0.001), Black (OR: 1.65; p < 0.001) or Asian (OR: 1.33; p = 0.014) race, Charlson score 2 (OR: 1.33; p = 0.005) or 3 (OR: 1.55; p < 0.001), urban residence (OR: 1.21; p = 0.003), abdominoperineal resection (OR: 1.69; p < 0.001), pelvic exenteration (OR: 1.7; p = 0.002), and robotic-assisted surgery (OR: 1.22; p = 0.001). Medicare (OR: 0.725; p = 0.003) and private insurance (OR: 0.711; p < 0.001) were associated with better adherence. 30-day and 90-day mortality, unplanned readmission, and overall survival were similar.

CONCLUSIONS

Male Black or Asian patients with high Charlson scores, and undergoing abdominoperineal resection, pelvic exenteration, and robotic-assisted surgery were more likely non-adherent with NAPRC standards with >60 days delay before definitive surgery for rectal cancer. Hopefully, recognition for these reasons for delay of definitive surgery will lead to an improvement in adherence to the standards.

The effect of time before diagnosis and treatment on colorectal cancer outcomes: systematic review and dose-response meta-analysis

BACKGROUND

This systematic review and meta-analysis aimed to evaluate existing evidence on the relationship between diagnostic and treatment intervals and outcomes for colorectal cancer.

METHODS

Four databases were searched for English language articles assessing the role of time before initial treatment in colorectal cancer on any outcome, including stage and survival. Two reviewers independently screened articles for inclusion and data were synthesised narratively. A dose-response meta-analysis was performed to examine the association between treatment interval and survival.

RESULTS

One hundred and thirty papers were included in the systematic review, eight were included in the meta-analysis. Forty-five different intervals were considered in the time from first symptom to treatment. The most common finding was of no association between the length of intervals on any outcome. The dose-response meta-analysis showed a U-shaped association between the treatment interval and overall survival with the nadir at 45 days.

CONCLUSION

The review found inconsistent, but mostly a lack of, association between interval length and colorectal cancer outcomes, but study design and quality were heterogeneous. Meta-analysis suggests survival becomes increasingly poorer for those commencing treatment more than 45 days after diagnosis.

REGISTRATION

This review was registered, and the protocol is available, in PROSPERO, the international database of systematic reviews, with the registration ID CRD42021255864.

Hepatopancreatobiliary malignancies: time to treatment matters

Background

Initiation of oncologic care is often delayed, yet little is known about delays in hepatopancreatobiliary (HPB) cancers or their impact. This retrospective cohort study describes trends in time to treatment initiation (TTI), assesses the association between TTI and survival, and identifies predictors of TTI in HPB cancers.

Methods

The National Cancer Database was queried for patients with cancers of the pancreas, liver, and bile ducts between 2004 and 2017. Kaplan-Meier survival analysis and Cox regression were used to investigate the association between TTI and overall survival for each cancer type and stage. Multivariable regression identified factors associated with longer TTI.

Results

Of 318,931 patients with HPB cancers, median TTI was 31 days. Longer TTI was associated with increased mortality in patients with stages I-III extrahepatic bile duct (EHBD) cancer and stages I-II pancreatic adenocarcinoma. Patients treated within 3-30, 31-60, and 61-90 days had median survivals of 51.5, 34.9, and 25.4 months (log-rank P<0.001), respectively, for stage I EHBD cancer, and 18.8, 16.6, and 15.2 months for stage I pancreatic cancer, respectively (P<0.001). Factors associated with increased TTI included stage I disease (+13.7 days vs. stage IV, P<0.001), treatment with radiation only (β=+13.9 days, P<0.001), Black race (+4.6 days, P<0.001) and Hispanic ethnicity (+4.3 days, P<0.001).

Conclusions

Some HPB cancer patients with longer time to definitive care experienced higher mortality than patients treated expeditiously, particularly in non-metastatic EHBD cancer. Black and Hispanic patients are at risk for delayed treatment. Further research into these associations is needed.

A systematic review of methodological considerations in time to diagnosis and treatment in colorectal cancer research

Research focusing on timely diagnosis and treatment of colorectal cancer is necessary to improve outcomes for people with cancer. Previous attempts to consolidate research on time to diagnosis and treatment have noted varied methodological approaches and quality, limiting the comparability of findings. This systematic review was conducted to comprehensively assess the scope of methodological issues in this field and provide recommendations for future research. Eligible articles had to assess the role of any interval up to treatment, on any outcome in colorectal cancer, in English, with no limits on publication time. Four databases were searched (Ovid Medline, EMBASE, EMCARE and PsycInfo). Papers were screened by two independent reviewers using a two-stage process of title and abstract followed by full text review. In total, 130 papers were included and had data extracted on specific methodological and statistical features. Several methodological problems were identified across the evidence base. Common issues included arbitrary categorisation of intervals (n = 107, 83%), no adjustment for potential confounders (n = 65, 50%), and lack of justification for included covariates where there was adjustment (n = 40 of 65 papers that performed an adjusted analysis, 62%). Many articles introduced epidemiological biases such as immortal time bias (n = 37 of 80 papers that used survival as an outcome, 46%) and confounding by indication (n = 73, 56%), as well as other biases arising from inclusion of factors outside of their temporal sequence. However, determination of the full extent of these problems was hampered by insufficient reporting. Recommendations include avoiding artificial categorisation of intervals, ensuring bias has not been introduced due to out-of-sequence use of key events and increased use of theoretical frameworks to detect and reduce bias. The development of reporting guidelines and domain-specific risk of bias tools may aid in ensuring future research can reliably contribute to recommendations regarding optimal timing and strengthen the evidence base.

The relation of blood cell division control protein 42 level with disease risk, comorbidity, tumor features/markers, and prognosis in colorectal cancer patients

BACKGROUND

Cell division control protein 42 (CDC42) is involved in colorectal cancer (CRC) progression by modulating CD8⁺ T cell activation, immune escape, and direct oncogenetic biological processes. This study aimed to explore the correlation of blood CDC42 with disease risk, comorbidities, disease features, tumor markers, and prognosis among CRC patients.

METHODS

CDC42 in peripheral blood mononuclear cells was detected by reverse transcription-quantitative polymerase chain reaction from 250 resectable CRC patients and 50 healthy controls (HCs). CDC42 was divided by quartiles, as well as high and low expressions in CRC patients for correlation and survival analysis.

RESULTS

CDC42 was elevated in CRC patients vs. HCs (p < 0.001), which had a good ability to distinguish CRC patients from HCs with the area under the curve (95% confidence interval) of 0.889 (0.841-0.937). In CRC patients, CDC42 was not associated with demographics or comorbidities (all p > 0.05), while its higher quartile was linked to increased T stage (p < 0.001), N stage (p = 0.009), TNM stage (p < 0.001), abnormal carcinoembryonic antigen (p = 0.043), and adjuvant chemotherapy administration (p = 0.002). Higher CDC42 quartile (p = 0.002) and CDC42 high (vs. low) (p < 0.001) were related to worse disease-free survival (DFS); meanwhile, elevated CDC42 quartile (p = 0.002) and CDC42 high (vs. low) (p = 0.001) were also linked to poor overall survival (OS). Multivariate Cox's regression analysis presented that CDC42 quartile 3 and 4 (vs. quartile 1) independently predicted declined DFS and OS (all p < 0.05).

CONCLUSION

Circulating CDC42 relates to higher disease risk, T, N, and TNM stage, abnormal tumor marker, and poor prognosis among CRC patients.

The effect of the first year of the COVID-19 pandemic on sphincter preserving surgery for rectal cancer: A single referral center experience

Background

COVID-19 has significantly impacted healthcare worldwide. Lack of screening and limited access to healthcare has delayed diagnosis and treatment of various malignancies. The purpose of this study was to determine the effect of the first year of the COVID-19 pandemic on sphincter-preserving surgery in patients with rectal cancer.

Methods

This was a single-center retrospective study of patients undergoing surgery for newly diagnosed rectal cancer. Patients operated on during the first year of the COVID-19 pandemic (March 2020–February 2021) comprised the study group (COVID-19 era), while patients operated on prior to the pandemic (March 2016–February 2020) served as the control group (pre–COVID-19).

Results

This study included 234 patients diagnosed with rectal cancer; 180 (77%) patients in the pre–COVID-19 group and 54 patients (23%) in the COVID-19–era group. There were no differences between the groups in terms of mean patient age, sex, or body mass index. The COVID-19–era group presented with a significantly higher rate of locally advanced disease (stage T3/T4 79% vs 58%; P = .02) and metastatic disease (9% vs 3%; P = .05). The COVID-19–era group also had a much higher percentage of patients treated with total neoadjuvant therapy (52% vs 15%; P = .001) and showed a significantly lower rate of sphincter-preserving surgery (73% vs 86%; P = .028). Time from diagnosis to surgery in this group was also significantly longer (median 272 vs 146 days; P < .0001).

Conclusion

Patients undergoing surgery for rectal cancer during the first year of the COVID-19 pandemic presented later and at a more advanced stage. They were more likely to be treated with total neoadjuvant therapy and were less likely candidates for sphincter-preserving surgery.