Introduction As one of the most commonly diagnosed cancers in both males and females in the Western world, colorectal cancer (CRC) has been the focus for many new screening and treatment initiatives. With more than 23,300 new CRC cases and 9,200 deaths estimated to have occurred in Canada in 2012, optimizing patient care is imperative in improving survival [1] . While the foundation of CRC treatment is surgical resection, clinical trials have shown that adjuvant chemotherapy (AC) increases

more »

... val rates among CRC patients [2] . Currently, governing health institutions recommend that adjuvant chemotherapy is given to all high risk Stage II, as well as all stage III CRC patients, ideally within 8 weeks of surgical resection [3] [4] [5] . Cancer Care Ontario (CCO), a government health agency responsible for improving provincial cancer care in Ontario, Canada, has further broken down this timeline: Ontario cancer centres should aim for the time from the surgeon's referral to the medical oncology consult to be no longer than 14 days, and the consult to the start of treatment should be no longer than 28 days [6] . While clinical guidelines for CRC recommend commencing AC within 6 to 8 weeks of surgical resection, the optimal timing for treatment was not well studied until recently. In a recent systematic review and meta-analysis, Biagi et al. [7] investigated the association between the time to AC and survival outcomes in CRC patients. Their findings suggest that longer wait times are associated with worse survival outcomes, with relative overall survival decreasing by 14% for every 4-week delay to the initiation of treatment. Therefore, AC should begin within 4 to 6 weeks of surgical resection. Despite the discrepancies between guidelines and recent reviews, it is clear that timing is of paramount importance for CRC patients receiving adjuvant treatment. Several systemic and patient-related barriers, such as post-surgical complications or co-morbidities, have been identified as possible reasons for delay of AC. A retrospective review conducted as St. Michael's Hospital (SMH), an inner-city academic Toronto hospital, aimed to determine institutional wait times and elucidate barriers to receiving timely treatment. Patients at SMH waited an average of 7.2 weeks between surgery and AC, with only 37.1% of patients being treated between 4 to 6 weeks [8] . Furthermore, the presence of a post-surgical complication and timely referral to a medical oncologist were identified as the most significant clinical and systemic barriers to treatment, respectively [8]. To critically evaluate treatment wait times in CRC patients and identify clinical and systemic barriers to treatment, a retrospective study was conducted at both SMH and Mount Sinai Hospital (MSH) in Toronto. With a larger sample size, this study aimed to further the investigation of treatment wait times and barriers to optimal AC. Methods A retrospective review was conducted of CRC patients at two Toronto hospitals: SMH and MSH. Patients who were diagnosed with stage II or III CRC between January 1, 2005 and April 30, 2012, and underwent surgical resection and AC at each respective hospital were eligible for analysis. Of 797 patients diagnosed within this time period, 314 met the above eligibility criteria. Patient demographics were collected in addition to time from surgery to first AC, and systemic and clinical barriers to treatment. Descriptive statistics were calculated for each variable of interest, and t-tests were performed to test for associations with continuous variables. P-values<0.05 were assumed to be significant. This study received research ethics board approval from both participating hospitals. Results Of the 314 CRC patients who met the eligibility criteria, the median age was 61.5 years (range 23-91). Further patient demographics, such as stage of disease and treatment regimen, were collected and are summarized in Table 1. Among these clinical factors, the presence of a post-surgical complication was associated with delay in AC compared to those without post-surgical complications (10.6 days, p<0.001), as seen in Figure 1 . An association between tumour site and delay (p<0.001) was also observed, as illustrated in Figure 2 . The mean time from surgical resection to AC for these patients was 57.4 days (sd=16.8) or 8.2 weeks (range 4.1-18.7). Only 17.8% of patients started AC within 6 weeks of surgical resection, and only 49.7% of patients started within the recommended 8 weeks from surgery. The treatment timeline was further broken down into its individual components: time from surgery to referral averaged 20 days, time from the medical oncology consult to first AC averaged 26.5 days (sd=30.8), including 23 days awaiting port-a-cath insertion. Upon further correlational analysis, all of these individual timeline components correlate with a delay in the initiation of AC, with a significant p-value <0.05. Discussion Despite the CCO recommendations that AC should be initiated within 8 weeks of surgical resection, only 49.7% of CRC patients at SMH and MSH were being treated within these guidelines. Even fewer patients (17.8%) started treatment within 6 weeks of surgery, Volume 2 • Issue 1 • 1000110 Chemotherapy ISSN: 2167-7700 CMT, an open access journal the optimal time frame suggested by a recent analysis [7] . It is evident that timely CRC treatment needs to be further optimized to ultimately improve patient outcomes, including overall survival. In most cases, clinical barriers associated with delay to AC are harder to overcome. In this study, both tumour site and post-surgical complications were identified as clinical barriers. While tumour site is an unmodifiable factor, post-surgical complications can be minimized by employing best practices in wound care and surgical technique. However, improvement of quality patient care should focus on the surmountable systemic barriers to timely treatment. Time from surgery to a medical oncology referral, time awaiting port-a-cath insertion, and time from consult to first AC were all identified as such barriers. This highlights the importance of timely referrals amongst healthcare professionals, and the value of a cohesive multidisciplinary approach to oncology patient care. Pathologists, surgeons, medical oncologists, and other healthcare team members must work together and communicate seamlessly to streamline the referral process, and minimize the time between surgical resection and AC for optimal patient outcomes. Acknowledgement