Delays in the Cancer Pathway from Symptom Onset to Initiation of Treatment – A Retrospective Study in Patients with Non-Hodgkin’s Lymphoma.

Background: Cancer patients may experience significant delays along the clinical pathway from the onset of symptoms to initiation of treatment. Few studies have examined the nature or the extent of these delays in patients with non-Hodgkin’s lymphoma (NHL).

Method: London Regional Cancer Program (LRCP) is a tertiary care centre with a referral base of 1.5 million people in Southwestern Ontario. In this study, the charts of all patients with newly diagnosed NHL that were seen at the LRCP between Jan 1 – Dec 31, 2004 were reviewed retrospectively in order to measure and document the amount of time spent at each stage of the cancer pathway. Key time intervals from symptom onset to initiation of treatment were recorded. Associations between the waiting times and clinical/sociodemographic factors were also explored.

Results: The charts of 116 patients were reviewed. The median overall waiting time from symptom onset to the initiation of treatment was 137 days. Median waiting time for each interval in the pathway were as follows: from symptom onset to first visit with primary care physician: 17 days; from first visit with physician to surgical consultation: 28 days; from surgical consult to the definitive biopsy: 13 days; from definitive biopsy to pathological diagnosis: 10 days; from pathological diagnosis to hematology referral: −5 days; from hematology referral to hematology consultation: 8 days; from hematology consult to completion of staging: 8 days; and from final staging to initiation of treatment: 5 days. The time from symptom onset to treatment initiation varied somewhat by clinical factors such as gender, age, and presence of B-symptoms. Patients with B-symptoms experienced shorter delays (119 d) than patients without B-symptoms (154 d). Male patients had shorter pathway times (113 d) compared to female patients (138 d). Patients at the extremes of age (age 20–29 & age >80) tended to have shorter delays than patients between the ages of 30–79 (ages 20–29: 60d, age >80: 85d, ages 30–79:137 d). Whether patients were referred from London vs. from another municipality did not appear to influence delays (137 d).

Conclusions: NHL patients are experiencing significant delays in the assessment and treatment of their cancer. Most prior studies have focused primarily on delays from the point of referral to a cancer specialist to initiation of treatment. The results from our study suggest that a significant proportion of the patient’s clinical path is being spent at the prediagnosis phase (from the time of first physician visit until pathological diagnosis, 57 days) as opposed to from the time of diagnosis until the initiation of treatment (18 days). Efforts to reduce delays at both the pre- and post-diagnosis phases of the patient path may reduce patient anxiety with subsequent improvements in quality of life. The clinical impact of these delays on patient outcome is uncertain and requires further study.