A patient-centred approach toward surgical wait times for colon cancer: a population-based analysis

Association of time to resection with survival in patients with colon cancer

PURPOSE

Colon cancer (CC) remains a leading cause of cancer-related mortality worldwide, for which colectomy represents the standard of care. Yet, the impact of delayed resection on survival outcomes remains controversial. We assessed the association between time to surgery and 10-year survival in a national cohort of CC patients.

METHODS

This retrospective cohort study identified all adults who underwent colectomy for Stage I-III CC in the 2004-2020 National Cancer Database. Those who required neoadjuvant therapy or emergent resection < 7 days from diagnosis were excluded. Patients were classified into Early (< 25 days) and Delayed (≥ 25 days) cohorts after an adjusted analysis of the relationship between time to surgery and 10-year survival. Survival at 1-, 5-, and 10-years was assessed via Kaplan-Meier analyses and Cox proportional hazard modeling, adjusting for age, sex, race, income quartile, insurance coverage, Charlson-Deyo comorbidity index, disease stage, location of tumor, receipt of adjuvant chemotherapy, as well as hospital type, location, and case volume.

RESULTS

Of 165,991 patients, 84,665 (51%) were classified as Early and 81,326 (49%) Delayed. Following risk adjustment, Delayed resection was associated with similar 1-year [hazard ratio (HR) 1.01, 95% confidence interval (CI) 0.97-1.04, P = 0.72], but inferior 5- (HR 1.24, CI 1.22-1.26; P < 0.001) and 10-year survival (HR 1.22, CI 1.20-1.23; P < 0.001). Black race [adjusted odds ratio (AOR) 1.36, CI 1.31-1.41; P < 0.001], Medicaid insurance coverage (AOR 1.34, CI 1.26-1.42; P < 0.001), and care at high-volume hospitals (AOR 1.12, 95%CI 1.08-1.17; P < 0.001) were linked with greater likelihood of Delayed resection.

CONCLUSIONS

Patients with CC who underwent resection ≥ 25 days following diagnosis demonstrated similar 1-year, but inferior 5- and 10-year survival, compared to those who underwent surgery within 25 days. Socioeconomic factors, including race and Medicaid insurance, were linked with greater odds of delayed resection. Efforts to balance appropriate preoperative evaluation with expedited resection are needed to optimize patient outcomes.

Small-Area Geographic and Socioeconomic Inequalities in Colorectal Cancer in Cyprus

Colorectal cancer (CRC) is one of the leading causes of death and morbidity worldwide. To date, the relationship between regional deprivation and CRC incidence or mortality has not been studied in the population of Cyprus. The objective of this study was to analyse the geographical variation of CRC incidence and mortality and its possible association with socioeconomic inequalities in Cyprus for the time period of 2000-2015. This is a small-area ecological study in Cyprus, with census tracts as units of spatial analysis. The incidence date, sex, age, postcode, primary site, death date in case of death, or last contact date of all alive CRC cases from 2000-2015 were obtained from the Cyprus Ministry of Health's Health Monitoring Unit. Indirect standardisation was used to calculate the sex and age Standardise Incidence Ratios (SIRs) and Standardised Mortality Ratios (SMRs) of CRC while the smoothed values of SIRs, SMRs, and Mortality to Incidence ratio (M/I ratio) were estimated using the univariate Bayesian Poisson log-linear spatial model. To evaluate the association of CRC incidence and mortality rate with socioeconomic deprivation, we included the national socioeconomic deprivation index as a covariate variable entering in the model either as a continuous variable or as a categorical variable representing quartiles of areas with increasing levels of socioeconomic deprivation. The results showed that there are geographical areas having 15% higher SIR and SMR, with most of those areas located on the east coast of the island. We found higher M/I ratio values in the rural, remote, and less dense areas of the island, while lower rates were observed in the metropolitan areas. We also discovered an inverted U-shape pattern in CRC incidence and mortality with higher rates in the areas classified in the second quartile (Q2-areas) of the socioeconomic deprivation index and lower rates in rural, remote, and less dense areas (Q4-areas). These findings provide useful information at local and national levels and inform decisions about resource allocation to geographically targeted prevention and control plans to increase CRC screening and management.

Clinical Delays and Comparative Outcomes in Younger and Older Adults with Colorectal Cancer: A Systematic Review

Outcome disparities between adults <50 with colorectal cancer (CRC) and older adults may be explained by clinical delays. This study synthesized the literature comparing delays and outcomes between younger and older adults with CRC. Databases were searched until December 2021. We included studies published after 1990 reporting delay in adults <50 that made comparisons to older adults. Comparisons were described narratively and stage between age groups was meta-analyzed. 39 studies were included representing 185,710 younger CRC patients and 1,422,062 older patients. Sixteen delay intervals were compared. Fourteen studies (36%) found significantly longer delays among younger adults, and nine (23%) found shorter delays among younger patients. Twelve studies compared time from symptom onset to diagnosis (N younger = 1538). Five showed significantly longer delays for younger adults. Adults <50 years also had higher odds of advanced stage (16 studies, pooled OR for Stage III/IV 1.76, 95% CI 1.52-2.03). Ten studies compared time from diagnosis to treatment (N younger = 171,726) with 4 showing significantly shorter delays for younger adults. All studies showing longer delays for younger adults examined pre-diagnostic intervals. Three studies compared the impact of delay on younger versus older adult. One showed longer delays were associated with advanced stage and worse survival in younger but not older adults. Longer delays among younger adults with CRC occur in pre-diagnostic intervals.

Time to diagnosis and treatment in younger adults with colorectal cancer: A systematic review

Background

The incidence of colorectal cancer is rising in adults <50 years of age. As a primarily unscreened population, they may have clinically important delays to diagnosis and treatment. This study aimed to review the literature on delay intervals in patients <50 years with colorectal cancer (CRC), and explore associations between longer intervals and outcomes.

Methods

MEDLINE, Embase, and LILACS were searched until December 2, 2021. We included studies published after 1990 reporting any delay interval in adults <50 with CRC. Interval measures and associations with stage at presentation or survival were synthesized and described in a narrative fashion. Risk of bias was assessed using the Newcastle-Ottawa Scale, Institute of Health Economics Case Series Quality Appraisal Checklist, and the Aarhus Checklist for cancer delay studies.

Results

55 studies representing 188,530 younger CRC patients were included. Most studies used primary data collection (64%), and 47% reported a single center. Sixteen unique intervals were measured. The most common interval was symptom onset to diagnosis (21 studies; N = 2,107). By sample size, diagnosis to treatment start was the most reported interval (12 studies; N = 170,463). Four studies examined symptoms onset to treatment start (total interval). The shortest was a mean of 99.5 days and the longest was a median of 217 days. There was substantial heterogeneity in the measurement of intervals, and quality of reporting. Higher-quality studies were more likely to use cancer registries, and be population-based. In four studies reporting the relationship between intervals and cancer stage or survival, there were no clear associations between longer intervals and adverse outcomes.

Discussion

Adults <50 with CRC may have intervals between symptom onset to treatment start greater than 6 months. Studies reporting intervals among younger patients are limited by inconsistent results and heterogeneous reporting. There is insufficient evidence to determine if longer intervals are associated with advanced stage or worse survival.

Other

This study’s protocol was registered with the Prospective Register of Systematic Reviews (PROSPERO; registration number CRD42020179707).

Time to treatment of esophageal cancer in Ontario: A population-level cross-sectional study

Objective

Timely cancer treatment improves survival and anxiety for some sites. Patients with esophageal cancer require specific workup before treatment, which can prolong the time from diagnosis to treatment (treatment interval [TI]). The geographical variation of this interval remains uninvestigated in patients with esophageal cancer.

Methods

This retrospective population-level study conducted in Ontario used linked administrative health care databases. Patients treated for esophageal cancer between 2013 and 2018 were included. The TI was time from diagnosis to treatment. Patients were assigned a geographical Local Health Integration Network on the basis of postal code. Covariates included patient, disease, and diagnosing physician characteristics. Quantile regression modeled TI length at the 50th and 90th percentile and identified associated factors.

Results

Of 7509 patients, 78% were male and most were aged between 60 and 69 years. The 50th and 90th percentile TI was 36 (interquartile range, 22-55) and 77 days, respectively. The difference between the Local Health Integration Network with the longest and shortest TI at the 50th and 90th percentile was 18 and 25 days, respectively. Older age (P < .0001), greater comorbidity (P = .0005), greater material deprivation (P = .001), rurality (P = .03), histology (P = .02), and treatment group (P < .0001) were associated with a longer median TI. Older age (P = .03), greater comorbidity (P = .003), greater material deprivation (P = .005), rurality (P = .04), and treatment group (P < .0001) were associated with a longer 90th percentile TI.

Conclusions

Geographic variability of time to treatment exists across Ontario. Investigation of facility-level differences is warranted. Patient and disease factors are associated with longer wait times. These results might inform future health care policy and resource allocation.

Time to Surgery for Patients with Esophageal Cancer Undergoing Trimodal Therapy in Ontario: A Population-Based Cross-Sectional Study

Patients with resectable esophageal cancer are recommended to undergo chemoradiotherapy before esophagectomy. A longer time to surgery (TTS) and/or time to consultation (TTC) may be associated with inferior cancer-related outcomes and heightened anxiety. Thoracic cancer surgery centers (TCSCs) oversee esophageal cancer management, but differences in TTC/TTS between centers have not yet been examined. This Ontario population-level study used linked administrative healthcare databases to investigate patients with esophageal cancer between 2013–2018, who underwent neoadjuvant chemoradiotherapy and then surgery. TTC and TTS were time from diagnosis to the first surgical consultation and then to surgery, respectively. Patients were assigned a TCSC based on the location of the surgery. Patient, disease, and diagnosing physician characteristics were investigated. Quantile regression was used to model TTS/TTC at the 50th and 90th percentiles and identify associated factors. The median TTS and TTC were 130 and 29 days, respectively. The adjusted differences between the TCSCs with the longest and shortest median TTS and TTC were 32 and 18 days, respectively. Increasing age was associated with a 16-day longer median TTS. Increasing material deprivation was associated with a 6-day longer median TTC. Significant geographic variability exists in TTS and TTC. Therefore, the investigation of TCSC characteristics is warranted. Shortening wait times may reduce patient anxiety and improve the control of esophageal cancer.

Ontario wait times for delayed surgical treatment of traumatic peripheral nerve injury

Background:

To better understand the occurrence and operative treatment of peripheral nerve injury (PNI) and the potential need for additional resources, it is essential to define the frequency and distribution of peripheral nerve procedures being performed. The objective of this study was to evaluate Ontario’s wait times for delayed surgical treatment of traumatic PNI.

Methods:

We retrieved data on wait times for peripheral nerve surgery from the Ontario Ministry of Health and Long-Term Care Wait Time Information System. We reviewed the wait times for delayed surgical treatment of traumatic PNI among adult patients (age ≥ 18 yr) from April 2009 to March 2018. Data collected included total cases, mean and median wait times, and demographic characteristics.

Results:

Over the study period, 7313 delayed traumatic PNI operations were reported, with variability in the case volume distribution across Local Health Integration Networks (LHINs). The highest volume of procedures (2788) was performed in the Toronto Central LHIN, and the lowest volume (< 6) in the Waterloo Wellington and North Simcoe Muskoka LHINs. The population incidence of traumatic PNI requiring surgery was 5.1/10 000. The mean and median wait times from surgical decision to surgical repair were 45 and 27 days, respectively. Both the longest and shortest wait times occurred in LHINs with low case volumes. The provincial target wait time was met in 93% of cases, but women waited significantly longer than men (p < 0.001).

Conclusion:

The provincial distribution of traumatic PNI surgery was variable, and the highest volumes were in the LHINs with large populations. The provincial wait time strategy for traumatic PNI surgery is effective, but women waited longer than men. Precise reporting from all hospitals is necessary to accurately capture and understand the delivery of care after traumatic PNI.

Reliance on Self-Medication Increase Delays in Diagnosis and Management of GI Cancers: Results From Nepal

PURPOSE

Patients with GI cancers in Nepal often present with advanced disease and poor outcomes. The purpose of the study was to determine the time to presentation, diagnosis, and treatment of GI cancer and the baseline factors that may be associated with delays.

PATIENTS AND METHODS

An institutional review board–approved study was performed in Kathmandu, Nepal, from July 2018 to June 2019. Patients with newly diagnosed GI cancers were asked to fill out a standardized questionnaire. Baseline factors such as residence, literacy, and use of self-medication were recorded. Patients were asked to report the time from first symptom to presentation, time from primary care visit to pathologic diagnosis, and time from diagnosis to surgery and/or treatment. Baseline factors were analyzed using 2-tailed t tests (Prism 8.0; GraphPad, La Jolla, CA) to determine whether any factors were associated with longer time delays in these 3 intervals.

RESULTS

The cohort comprised of 104 patients with a median age of 53.5 years (range, 22-77 years); 61.5% were men, 46.2% had upper GI cancers, and 83.7% presented with stage III or IV disease. The median time to presentation was 150 days, time to diagnosis was 220 days, and time to treatment was 50 days. There was no statistically significant difference in time intervals between upper and lower GI cancers. Use of self-medication (88.5%) was the only factor associated with longer time intervals to presentation, diagnosis, and treatment.

CONCLUSION

Patients in Nepal have long time intervals to presentation, diagnosis, and treatment of GI cancer. Self-medication led to longer delays. Reasons for self-medication and other potential barriers will be explored in future studies in the hopes of improving outcomes.

Impact of a Geriatric Intervention to Improve Screening and Management of Undernutrition in Older Patients Undergoing Surgery for Colorectal Cancer: Results of the ANC Stepped-Wedge Trial

Almost two in three patients who are aged 75 years and older and scheduled for surgery for colorectal cancer (CRC) are undernourished. Despite evidence that perioperative nutritional management can improve patients outcomes, international guidelines are still insufficiently applied in current practice. In this stepped-wedge cluster-randomized study of five surgical hospitals, we included 147 patients aged 70 years or older with scheduled abdominal surgery for CRC between October 2013 and December 2016. In the intervention condition, an outreach team comprising a geriatrician and a dietician visited patients and staff in surgical wards to assist with the correct application of guidelines. Evaluation, diagnosis, and prescription (according to nutritional status) were considered appropriate and strictly consistent with guidelines in 39.2% of patients in the intervention group compared to only 1.4% in the control group (p = 0.0002). Prescription of oral nutritional supplements during the perioperative period was significantly improved (41.9% vs. 4.1%; p < 0.0001). However, there were no benefits of the intervention on surgical complications or adverse events. A possible benefit of hospital stay reduction will need to be confirmed in further studies. This study highlights the importance of the implementation of quality improvement interventions into current practice for the perioperative nutritional management of older patients with CRC.

Barriers to colonoscopy in remote northern Canada: an analysis of cancellations

Background: Colonoscopy is a critical diagnostic and therapeutic procedure that is challenging to access in northern Canada. In part, this is due to frequent cancellations. We sought to understand the trends and reasons for colonoscopy cancellations in the Northwest Territories (NWT).

Methods: A retrospective review of colonoscopy cancellations January, 2018 to May, 2019 was conducted at Stanton Territorial Hospital, NWT. Cancellation details and rationale were captured from the endoscopy cancellation logs. Thematic analysis was used to group cancellation reasons. Descriptive statistics were generated, and trends were analysed using run chart.

Results: Of the scheduled colonoscopies, 368(28%) were cancelled during the 16 month period, and cancellations occurred, on average, 27 days after booking. Cancellation reasons were grouped into 15 themes, encompassing personal, social, geographic and health system factors. The most frequently cited theme was work/other commitments (69 respondents; 24%). Cancellations due to travel and accommodation issues occurred more frequently in the winter.

Conclusion: Over one in four booked colonoscopies were cancelled and the reasons for cancellations were complex. Initiatives focusing on communication and support for patients with personal or occupational obligations could dramatically reduce cancellations. Ongoing collaborative efforts are needed to inform and optimise access to colonoscopy in this region.

The experience with colorectal cancer screening in the Czech Republic: the detection at earlier stages and improved clinical outcomes

OBJECTIVES

Colorectal cancer (CRC) remains a major health burden. Although screening is recommended and considered beneficial, further data on its positive effects are needed for worldwide implementation.

STUDY DESIGN

The aim of our national multicentre prospective observational study was to reveal and document clinicopathological differences in CRC diagnosed by screening and presented by disease symptoms as well as assess the efficiency of the screening programme in the Czech Republic.

METHODS

Between March 2013 and September 2015, a total of 265 patients were enrolled in 12 gastroenterology centres across the Czech Republic. Patients were divided into screening and symptomatic groups and compared for pathology status and clinical characteristics. Screening was defined as a primary screening colonoscopy or a colonoscopy after a positive faecal occult blood test in an average-risk population.

RESULTS

The distribution of CRC stages was significantly (statistically and clinically) favourable in the screening group (predominance of stages 0, I and II) compared with the non-screening group (P < 0.001). The presence of distant and local metastases was significantly less frequent in the screening group than in the symptomatic group (P < 0.001). Patients in the screening group had a higher probability of radical surgery (R0) than those diagnosed based on symptoms (P < 0.001). Systemic palliative treatment was indicated in two patients in the screening group compared with 23 patients in the non-screening group (P = 0.018).

CONCLUSION

CRC diagnosed by screening disclosed less advanced clinicopathological characteristics and results in patients with a higher probability of radical surgery (R0) than diagnoses established based on symptoms, with subsequent management differing accordingly between both groups. These results advocate the implementation of a suitable worldwide screening programme.

Impact of surgical wait times on oncologic outcomes in resectable pancreas adenocarcinoma

BACKGROUND

Timely surgical resection in patients with suspected or diagnosed pancreas adenocarcinoma is an essential part of care. We hypothesized that longer surgical wait time was associated with worse oncologic outcomes.

METHODS

A retrospective cohort of patients (N = 144) with resectable pancreas adenocarcinoma was divided into four wait time groups (<4, 4-8, 8-12, and >12 weeks), defined from the time of diagnosis on cross-sectional imaging. Overall and recurrence-free survival were analyzed using the Kaplan-Meier method and Cox proportional hazards regression. A higher rate of conversion to palliative bypass in patients waiting over 4 weeks was observed and further analyzed using post-hoc multivariate regression.

RESULTS

On multivariable analysis, longer wait time was associated with improved overall (HR 0.49, 95% CI: 0.28-0.85) and recurrence-free survival (HR 0.29, 95% CI: 0.15-0.56) in >12 weeks compared to <4 weeks group. On post-hoc analysis, longer wait time over 8 weeks was positively associated with palliative bypass (OR 5.33, 95% CI: 1.32-27.88).

CONCLUSION

Wait time over 8 weeks was associated with a higher rate of palliative bypass. There was an improvement in overall and recurrence-free survival in patients who waited over 12 weeks, likely due to selection bias.

Care of acute conditions and chronic diseases in Canada and the United States: Rapid systematic review and meta-analysis

This study tested the hypothesis that socioeconomically vulnerable Canadians with diverse acute conditions or chronic diseases have health care access and survival advantages over their counterparts in the USA. A rapid systematic review retrieved 25 studies (34 independent cohorts) published between 2003 and 2018. They were synthesized with a streamlined meta-analysis. Very low-income Canadian patients were consistently and highly advantaged in terms of health care access and survival compared with their counterparts in the USA who lived in poverty and/or were uninsured or underinsured. In aggregate and controlling for specific conditions or diseases and typically 4 to 9 comorbid factors or biomarkers, Canadians' chances of receiving better health care were estimated to be 36% greater than their American counterparts (RR=1.36, 95% CI 1.35-1.37). This estimate was significantly larger than that based on general patient or non-vulnerable population comparisons (RR=1.09, 95% CI 1.08-1.10). Contrary to prevalent political rhetoric, three studies observed that Americans experience more than twice the risk of long waits for breast or colon cancer care or of dying while they wait for an organ transplant (RR=2.36, 95% CI 2.09-2.66). These findings were replicated across externally valid national studies and more internally valid, metropolitan or provincial/state comparisons. Socioeconomically vulnerable Canadians are consistently and highly advantaged on health care access and outcomes compared to their American counterparts. Less vulnerable comparisons found more modest Canadian advantages. The Affordable Care Act ought to be fully supported including the expansion of Medicaid across all states. Canada's single payer system ought to be maintained and strengthened, but not through privatization.

Can we improve the efficiency of care in patients with colorectal cancer from the time of their initial referral for colonoscopy to surgical resection?

Summary

Delays in the diagnosis and treatment of colon adenocarcinoma are distressing to patients and clinicians alike. Of 224 patients with resected colon cancer identified via a province-wide administrative database, 170 (76%) received their colonoscopy from a gastroenterologist (GI). Patients waited significantly longer between their colonoscopy and surgical resection when the colonoscopy was performed by a GI within an urban city (43 v. 27 d; p = 0.02). The total time from family practice referral to colonoscopy to surgical resection was shorter when a surgeon performed colonoscopy within an urban setting (105 v. 114 d; p = 0.03). In community settings, there were no significant differences in any interval, regardless of which service performed the colonoscopy.

Exercise prehabilitation in elective intra-cavity surgery: A role within the ERAS pathway? A narrative review

The Enhanced Recovery after Surgery (ERAS) model integrates several elements of perioperative care into a standardised clinical pathway for surgical patients. ERAS programmes aim to reduce the rate of complications, improve surgical recovery, and limit postoperative length of hospital stay (LOHS). One area of growing interest that is not currently included within ERAS protocols is the use of exercise prehabilitation (PREHAB) interventions. PREHAB refers to the systematic process of improving functional capacity of the patient to withstand the upcoming physiological stress of surgery. A number of recent systematic reviews have examined the role of PREHAB prior to elective intra-cavity surgery. However, the results have been conflicting and a definitive conclusion has not been obtained. Furthermore, a summary of the research area focussing exclusively on the therapeutic potential of exercise prior to intra-cavity surgery is yet to be undertaken. Clarification is required to better inform perioperative care and advance the research field. Therefore, this "review of reviews" provides a critical overview of currently available evidence on the effect of exercise PREHAB in patients undergoing i) coronary artery bypass graft surgery (CABG), ii) lung resection surgery, and iii) gastrointestinal and colorectal surgery. We discuss the findings of systematic reviews and meta-analyses and supplement these with recently published clinical trials. This article summarises the research findings and identifies pertinent gaps in the research area that warrant further investigation. Finally, studies are conceptually synthesised to discuss the feasibility of PREHAB in clinical practice and its potential role within the ERAS pathway.

Do Moderate Surgical Treatment Delays Influence Survival in Colon Cancer?

BACKGROUND

Studies examining treatment delay and survival after surgical treatment of colon cancer have varied in quality and outcome, with little evidence available regarding the safety of longer surgical treatment wait times.

OBJECTIVE

Our study examined the effect of surgical treatment wait times on survival for patients with stage I to III colon cancer.

DESIGN

A subset cohort analysis was performed using data from a prospectively maintained database.

SETTINGS

The study was conducted at a tertiary referral center.

PATIENTS

Data on all of the patients undergoing elective surgery for stage I to III colon cancer from 2006 to 2015 were collected from a prospectively maintained clinical and administrative database.

MAIN OUTCOME MEASURES

We examined the impact of prolonged wait time to surgery on disease-free and overall survival. Patients were divided into 2 groups based on a treatment wait time of ≤30 or >30 days and were compared using a Cox proportional hazards model. A subgroup analysis was performed using alternative treatment delay cutoffs of 60 and 90 days.

RESULTS

There were 908 patients with stage I to III colon cancer treated over the study period, with a median treatment wait time of 38 days (interquartile range, 21-61 days); 368 patients were treated within 30 days, and 540 were treated beyond 30 days from diagnosis. In adjusted multivariate analysis, a treatment delay of >30 days was not associated with decreased disease-free survival (HR = 0.89 (95% CI, 0.61-1.3); p = 0.52) or overall survival (HR = 0.82 (95% CI, 0.63-1.1); p = 0.16). Likewise, subgroup analysis using alternative treatment delay cutoffs of 60 and 90 days did not demonstrate an adverse effect on survival.

LIMITATIONS

This study was limited by retrospective analysis.

CONCLUSIONS

Despite longer median treatment wait times from diagnosis to surgery, with the majority of patients exceeding 30 days and many experiencing delays of 2 to 3 months, no adverse impact on survival was observed. Patients who require additional consultations or investigations preoperatively may safely have their surgery moderately delayed to minimize their perioperative risk without any evidence that this will compromise treatment outcomes. See Video Abstract at http://links.lww.com/DCR/A397.

Association between the time to surgery and survival among patients with colon cancer: A population-based study

Factors associated with time-to-surgery (TTS) and survival in colon cancer has not been well studied. Cancer Care Ontario recommends surgery within 42 days of diagnosis and that 90% of patients meet this benchmark. We describe factors associated with TTS and survival in routine clinical practice.

METHODS

Retrospective population-based cohort study of patients receiving elective colonic resection after diagnosis of colon cancer in Ontario, Canada from 2002 to 2008 followed until 2012. Factors associated with TTS were identified using multivariate log-binomial and Quantile regression at 42 days and 90th percentiles. The association between TTS and cancer-specific (CSS) and overall survival (OS) were examined using multivariate Cox regression.

RESULTS

4326 patients; median age 71 years and 52% male. Median TTS was 24 days (IQR 14-37); at the 90th percentile 56 days. Factors associated with TTS ≥ 42 days and >90th percentile included older age, co-morbid illness, surgeon volume, and stage I disease (P < 0.05 for all). In patients whose TTS was either at 42 days or 90th percentile, those ≥80 years old waited two weeks longer than those <60 years, individuals with co-morbid illness waited 10 days longer than without co-morbidity, and patients with stage I disease waited 10 days longer than those with stage IV disease (P < 0.05 for all). Delay in TTS > 42 days or >90th percentile was not associated with OS or CSS.

CONCLUSION

Age, co-morbidity, and stage of cancer are associated with TTS. There was no association between TTS and CSS or OS.

Time to Endoscopy in Patients with Colorectal Cancer: Analysis of Wait-Times

Objective. The Canadian Association of Gastroenterology Wait Time Consensus Group recommends that patients with symptoms associated with colorectal cancer (CRC) should have an endoscopic examination within 2 months. However, in a recent survey of Canadian gastroenterologists, wait-times for endoscopy were considerably longer than the current guidelines recommend. The purpose of this study was to evaluate wait-times for colonoscopy in patients who were subsequently found to have CRC through the Division of Gastroenterology at St. Paul's Hospital (SPH). Methods. This study was a retrospective chart review of outpatients seen for consultation and endoscopy ultimately diagnosed with CRC. Subjects were identified through the SPH pathology database for the inclusion period 2010 through 2013. Data collected included wait-times, subject characteristics, cancer characteristics, and outcomes. Results. 246 subjects met inclusion criteria for this study. The mean wait-time from primary care referral to first office visit was 63 days; the mean wait-time to first endoscopy was 94 days. Patients with symptoms waited a mean of 86 days to first endoscopy, considerably longer than the national recommended guideline of 60 days. There was no apparent effect of length of wait-time on node positivity or presence of distant metastases at the time of diagnosis. Conclusion. Wait-times for outpatient consultation and endoscopic evaluation at the St. Paul's Hospital Division of Gastroenterology exceed current guidelines.

Time to first treatment after colonoscopy in patients suffering from colon or rectum cancer in France

BACKGROUND

Time to treatment of cancer is becoming a serious political and social issue. A greater understanding of the timeframes involved in cancer care is needed to reduce inequalities in access to care caused by delays.

OBJECTIVE

To describe indicators of time to first treatment after colonoscopy in colon cancer (CC) and rectum cancer (RC) patients in France.

METHOD

Using the international classification of diseases and medical procedures codes, from national hospital discharge and long term illness databases we selected patients newly diagnosed for CC or RC in 2009-2010 who had undergone treatment.

RESULTS

We included 15 694 and 6 623 patients for CC and RC, respectively. Median times to surgery in patients with a surgical treatment pathway for CC and RC were 22 (Q1=14; Q3=34) and 97 (Q1=34; Q3=141) days, respectively. Median times to chemotherapy for patients with a non-surgical treatment pathway, for CC and RC were 36 (Q1=21; Q3=59) and 40 (Q1=27; Q3=59) days, respectively. The median time to radiotherapy in RC patients was 53 (Q1=39; Q3=78) days.Time to surgery as first treatment in RC patients (46 days) was twice as long as that in CC patients (22 days). Time to treatment was longer in most northern regions and in overseas districts, and shorter in southern regions, for both CC and RC.

CONCLUSION

The findings in this unprecedented study in France will inform decision-making policies on the future implementation of guidelines on timeframes for colorectal cancer treatment access.

Colon cancer care and survival: income and insurance are more predictive in the USA, community primary care physician supply more so in Canada

BACKGROUND

Our research group advanced a health insurance theory to explain Canada's cancer care advantages over America. The late Barbara Starfield theorized that Canada's greater primary care-orientation also plays a critically protective role. We tested the resultant Starfield-Gorey theory by examining the effects of poverty, health insurance and physician supplies, primary care and specialists, on colon cancer care in Ontario and California.

METHODS

We analyzed registry data for people with non-metastasized colon cancer from Ontario (n = 2,060) and California (n = 4,574) diagnosed between 1996 and 2000 and followed to 2010. We obtained census tract-based socioeconomic data from population censuses and data on county-level physician supplies from national repositories: primary care physicians, gastroenterologists and other specialists. High poverty neighborhoods were oversampled and the criterion was 10 year survival. Hypotheses were explored with standardized rate ratios (RR) and tested with logistic regression models.

RESULTS

Significant inverse associations of poverty (RR = 0.79) and inadequate health insurance (RR = 0.80) with survival were observed in the California, while they were non-significant or non-existent in Ontario. The direct associations of primary care physician (RRs of 1.32 versus 1.11) and gastroenterologist (RRs of 1.56 versus 1.15) supplies with survival were both stronger in Ontario than California. The supply of primary care physicians took precedence. Probably mediated through the initial course of treatment, it largely explained the Canadian advantage.

CONCLUSIONS

Poverty and health insurance were more predictive in the USA, community physician supplies more so in Canada. Canada's primary care protections were greatest among the most socioeconomically vulnerable. The protective effects of Canadian health care prior to enactment of the Affordable Care Act (ACA) clearly suggested the following. Notwithstanding the importance of insuring all, strengthening America's system of primary care will probably be the best way to ensure that the ACA's full benefits are realized. Finally, Canada's strong primary care system ought to be maintained.