Impact of time-to-treatment on survival for early-stage non-small cell lung cancer in The Netherlands-a nationwide observational cohort study

Background

Varied outcomes on the relation between time-to-treatment and survival in early-stage non-small cell lung cancer (NSCLC) patients are reported. We examined this relation in a large multicentric retrospective cohort study and identified factors associated with extended time-to-treatment.

Methods

We included 9,536 patients with clinical stage I-II NSCLC, diagnosed and treated in 2014-2019, from the Netherlands Cancer Registry that includes nation-wide data. Time-to-treatment was defined as the number of days between first outpatient visit for suspected lung cancer and start of treatment. The effect of extended time-to-treatment beyond the first quartile and survival was studied with Cox proportional hazard regression. Analyses were stratified for stage and type of therapy. Time-to-treatment was adjusted for multiple covariates including performance status and socioeconomic status. Factors associated with treatment delay were identified by multilevel logistic regression.

Results

Median time-to-treatment was 47 days [interquartile range (IQR): 34-65] for stage I and 46 days (IQR: 34-62) for stage II. The first quartile extended to 33 days for both stages. Risk of death increased significantly with extended time-to-treatment for surgical treatment of clinical stage II patients [adjusted hazard ratio (aHR) >33 days: 1.36, 95% confidence intervals (CI): 1.09-1.70], but not in stage II patients treated with radiotherapy or in stage I patients. Causes of prolonged time-to-treatment were multifactorial including diagnostic tests, such as endoscopic ultrasound (EUS) or endobronchial ultrasound (EBUS).

Conclusions

Clinical stage II patients benefit from fast initiation of surgical treatment. Surprisingly this appears to be accounted for by patients who are clinically stage II but pathologically stage I. Further study is needed on characterizing these patients and the significance of lymph node- or distant micrometastasis in guiding time-to-treatment and treatment strategy.

Impact of time-to-treatment on survival for advanced non-small cell lung cancer patients in the Netherlands: a nationwide observational cohort study

BACKGROUND

The assumption that more rapid treatment improves survival of advanced non-small cell lung cancer (NSCLC) has not yet been proven. We studied the relation between time-to-treatment and survival in advanced stage NSCLC patients in a large multicentric nationwide retrospective cohort. Additionally, we identified factors associated with delay.

METHOD

We selected 10 306 patients, diagnosed and treated between 2014 and 2019 for clinical stage III and IV NSCLC, from the Netherlands Cancer Registry that includes nationwide data from 109 Dutch hospitals. Associations between survival and time-to-treatment were tested with Cox proportional hazard regression analyses. Time-to-treatment was adjusted for multiple covariates including diagnostic procedures and type of therapy. Factors associated with delay were identified by multilevel logistic regression.

RESULTS

Risk of death significantly decreased with longer time-to-treatment for stage III patients receiving only radiotherapy (adjusted HR, aHR >21 days: 0.59 (95% CI 0.48 to 0.73)) or any type of systemic therapy (aHR >49 days: 0.72 (95% CI 0.56 to 0.91)) and stage IV patients receiving chemotherapy and/or immunotherapy (aHR >21 days: 0.81 (95% CI 0.73 to 0.88)). No significant association was found for stage III patients treated with chemoradiotherapy and stage IV patients treated with targeted therapy. More complex diagnostic procedures often delay treatment.

CONCLUSION

Although in general it is important to start treatment as early as possible, our study finds no evidence that a more rapid start of treatment improves outcomes in advanced stage NSCLC patients. The benefit of urgent treatment is probably confounded by unmeasured patient and tumour characteristics and, clinical urgency dictating timelines of treatment. Time-to-treatment and its impact should be continuously evaluated as therapeutic strategies continue to evolve and improve.

The Effect of Higher Level Computerized Clinical Decision Support Systems on Oncology Care: A Systematic Review

BACKGROUND

To deal with complexity in cancer care, computerized clinical decision support systems (CDSSs) are developed to support quality of care and improve decision-making. We performed a systematic review to explore the value of CDSSs using automated clinical guidelines, Artificial Intelligence, datamining or statistical methods (higher level CDSSs) on the quality of care in oncology.

MATERIALS AND METHODS

The search strategy combined synonyms for 'CDSS' and 'cancer.' Pubmed, Embase, The Cochrane Library, Institute of Electrical and Electronics Engineers, Association of Computing Machinery digital library and Web of Science were systematically searched from January 2000 to December 2019. Included studies evaluated the impact of higher level CDSSs on process outcomes, guideline adherence and clinical outcomes.

RESULTS

11,397 studies were selected for screening, after which 61 full-text articles were assessed for eligibility. Finally, nine studies were included in the final analysis with a total population size of 7985 patients. Types of cancer included breast cancer (63.1%), lung cancer (27.8%), prostate cancer (4.1%), colorectal cancer (3.1%) and other cancer types (1.9%). The included studies demonstrated significant improvements of higher level CDSSs on process outcomes and guideline adherence across diverse settings in oncology. No significant differences were reported for clinical outcomes.

CONCLUSION

Higher level CDSSs seem to improve process outcomes and guidelines adherence but not clinical outcomes. It should be noticed that the included studies primarily focused on breast and lung cancer. To further explore the impact of higher level CDSSs on quality of care, high-quality research is required.