Factors influencing treatment delays in a safety net hospital: teachable moments?

Abstract

<h3>Objectives:</h3> Delays in diagnosis and treatment of ovarian cancer contribute to decreased overall survival. A post-hoc analysis of a GOG study demonstrated that initiation of chemotherapy more than 25 days after surgery adversely affected survival. Furthermore, previous studies have shown that socio-demographic factors also play a role in treatment delays. We sought to determine factors contributing to delays in treatment initiation and reasons for delay in chemotherapy administration in patients receiving primary treatment of epithelial ovarian cancer at our safety net hospital. <h3>Methods:</h3> All patients with epithelial ovarian cancer seen between 1/1/2009 and 12/1/2019 were identified. Only patients who had primary chemotherapy at our safety net hospital were included. Demographic variables included race, ethnicity, median household income (MHI), and age for patients undergoing both primary cytoreductive surgery (PCRS) and neoadjuvant chemotherapy (NACT). A delay in initiation of chemotherapy was defined as > 25 days post surgery (whether undergoing PCRS or interval cytoreduction after NACT). Time to treatment initiation (TTI) was defined as date of gynecologic oncology consult to surgery (for PCRS) or first cycle of chemotherapy (for NACT). Delays between cycles of chemotherapy were noted through chart review. Linear regression analyses were performed using demographic variables as predictors for treatment duration (with p value set at 0.05). <h3>Results:</h3> 101 patients were identified that met inclusion criteria. The median age in this cohort was 61 years (range 25-82). 18 (17.8%) were Black and 75 (74.3%) were Hispanic. 81 (80.2%) patients had a MHI less than $60,000. 63 (62.4%) patients underwent PCRS and 38 (37.6%) patients underwent NACT. 77.2% of patients did not initiate adjuvant chemotherapy until > 25 days post surgery. The median TTI in the PCRS group was 15 days; however, 53 (84.1%) patients undergoing PCRS received their first cycle of chemotherapy > 25 days post surgery. The median TTI in the NACT group was 19 days, and 25 (65.8%) patients who completed NACT received their first cycle of adjuvant chemotherapy > 25 days after surgery. Black patients undergoing PCRS experienced a 30 day longer TTI than White patients (p=0.013). TTI for patients undergoing PCRS and living in an area with a median household income < $30,000 was 42 days versus 14 days in patients living in an area with median household income >$60,000 (p=0.033). In patients greater than 65 years old undergoing NACT, the time from interval cytoreductive surgery to adjuvant chemotherapy start was longer: 27 days for patients age < 65 years versus 39 days for patients ≥65 years (p=0.005). There were 76 total delays in chemotherapy administration identified. 39 (60.9%) of these were due to medical reasons and 37 (48.6%) were due to non-medical reasons. Specifically, 5 (6.5%) were due to regimen intolerance; 11 (14.5%) were due to hospitalizations or surgeries; 15 (19.7%) were due to patient factors such as transportation; 22 (28.9%) were due to scheduling barriers; and 23 (30.1%) were due to lab abnormalities. <h3>Conclusions:</h3> Significant delays exist in initiation of treatment and completion of treatment in patients receiving first line therapy for epithelial ovarian cancer. Race, income, and age were predictors of delays in treatment. Both medical as well as non-medical factors precluded timely delivery of treatment. Future quality studies at our institution will investigate whether these changes decrease delays in cancer care.