Variation in the time to treatment for stage III and IV non-small cell lung cancer patients for hospitals in the Netherlands

M Van De Ven,V.P Retèl,H Koffijberg,W.H Van Harten,M.J Ijzerman

doi:10.1016/j.lungcan.2019.05.023

Abstract

ObjectivesIncreased emphasis on molecular diagnostics can lead to increased variation in time to treatment (TTT) for patients with stage III and IV non-small cell lung cancer. This article presents the variation in TTT for advanced NSCLC patients observed in Dutch hospitals before the widespread use of immunotherapy. The aim of this article was to explore the variation in TTT between patients, as well as between hospitals. Material and methodsBased on the Netherlands Cancer Registry, we used patient-level data (n = 4096) from all 78 hospitals that diagnosed stage III or IV NSCLC in the Netherlands in 2016. To investigate how patient characteristics and hospital-level effects are associated with TTT (from diagnosis until start treatment), we interpreted regression model results for five common patient profiles to analyze the influence of age, gender, tumor stage, performance status, histology, and referral status as well as hospital-level characteristics on the TTT. Results and conclusionsTTT varies substantially between and within hospitals. The median TTT was 28 days with an inter-quartile range of 22 days. The hospital-level median TTT ranges from 17 to 68 days. TTT correlates significantly with tumor stage, performance status, and histology. The hospital-level effect, unrelated to hospital volume and type, affected TTT by several weeks at most. For most patients, TTT is within range as recommended in current guidelines. Variation in TTT seems higher for patients receiving either radiotherapy or targeted therapy, or for patients referred to another hospital and we hypothesize this is related to the complexity of the diagnostic pathway. With further advances in molecular diagnostics and precision oncology we expect variation in TTT to increase and this needs to be considered in designing optimal cancer care delivery.

Highlights

Non-small cell lung cancer (NSCLC) is a heterogeneous group of tumors that make up approximately 73% of lung cancers in the Netherlands [1]. 75% of patients with NSCLC are diagnosed with a tumor already at an advanced stage [2]
This study examines hospital variation in TTT by using patient-level data from the population-based Netherlands Cancer Registry (NCR) from all stage III or IV NSCLC diagnosing hospitals in the Netherlands to analyze the TTT for each hospital
We found a median TTT of 28 days and considerable variation in TTT between and within hospitals, for most patients, TTT is within the acceptable norms

Summary

Introduction

Non-small cell lung cancer (NSCLC) is a heterogeneous group of tumors that make up approximately 73% of lung cancers in the Netherlands [1]. 75% of patients with NSCLC are diagnosed with a tumor already at an advanced stage (stage IIIA, IIIB or IV) [2]. 75% of patients with NSCLC are diagnosed with a tumor already at an advanced stage (stage IIIA, IIIB or IV) [2]. These patients typically have a poor prognosis. Median survival times are approximately 2 and 9 months, for untreated patients with stage IV NSCLC and systemically treated patients with stage IV NSCLC, respectively [3]. Use of either treatment modalities requires detailed molecular testing for mutation analysis. Some of these molecular diagnostics can have a long turnaround time and potentially impose an increased time to treatment (TTT) [6]. While the association between TTT and mortality remains unclear in lung cancer [7], more evidence begins to indicate that a longer TTT is associated with poorer outcomes [8]

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