Does treatment delay affect survival in non-small cell lung cancer? A retrospective analysis from a single UK centre

Abstract

We analysed survival in relation both to time to treatment and other clinical parameters in the care pathway of non-small cell lung cancer (NSCLC) patients. Medical notes of 189 patients diagnosed with NSCLC presenting in 1998 were reviewed. Median time to treatment in all patients was 48 days. In multivariate analysis, time to treatment did not affect survival in patients with any stage of disease. Referral from general practitioner to chest department (P=0.032, HR=0.08), and absence of use of surgery (P=0.006, HR=30.30) were independently significant predictors of survival in stages 1 and 2 subgroup. In stage 3 patients, absence of laboratory abnormality (P=0.002, HR=0.39), and use of combined treatment (P=0.015, HR=0.17) were independent prognosticators. Lastly, in patients with stage 4 disease, presence of bone and/or liver metastasis (P=0.005, HR=2.65), and absence of use of chemotherapy (P<0.001, HR=6.25) were significantly associated with shorter survival. As survival is dependent on classical prognosticators, but not on time from referral to treatment (hospital delay), expanding resources in oncology (equipment, drugs and personnel), and, perhaps, reducing patient delay, rather than reducing hospital delay alone, could be better strategies to improve NSCLC survival.

Introduction

Early cancer diagnosis and treatment is naturally desirable [1]. It is of proven value in oral cancer [2] and cervical cancer [3], [4]. However, in breast cancer two recently published papers have given conflicting results [5], [6]. In non-small cell lung cancer (NSCLC) there appears to be no published evidence to date.

Cancer survival in Britain is lower than in her European neighbours both in general [7] and in lung cancer [8]. The mean survival in UK is under 6 months [9]. It is unclear whether Britain's poor performance relates to treatment delay, lack of treatment facilities [10] or an environmental factor.

Waiting time targets in the care pathway of NSCLC is a popular issue. In order to prevent treatment delay, the National Health Service policy is now for patients with suspected lung cancer to be seen by a specialist within 2 weeks of referral from the general practitioner (GP). The British Thoracic Society (BTS) and the Joint Collegiate Council for Oncology have also made recommendations on the times for referrals and waiting times in the treatment pathway [11], [12]. However, it is not known at present how time to treatment (i.e. patient, referral or hospital delay) affects NSCLC patients’ survival.

Numerous studies have analysed the importance of various prognostic factors in NSCLC. Performance status, gender, stage, number of metastatic sites and response to chemotherapy have been shown significant in predicting survival, in addition to a large number of parameters such as albumin, calcium, haemoglobin (Hb), lymphocyte count, lactate dehydrogenase (LDH), BUN, white cell count, neutrophil count, histological grading, arterial invasion, lymph vessel invasion, aneuploidy, tumour proliferative activity, microvessel count, Ki-67 antigen labelling and p53 gene mutation [13], [14], [15], [16], [17], [18], [19], [20], [21], [22].

For these reasons, we wished to analyse survival in relation both to time to treatment (hospital delay) and other known prognosticators, in a cohort of NSCLC patients presenting in 1 year in a UK Hospital with thoracic surgery and clinical oncology departments.