The "New Normal" of Cancer Treatment Delays Is Nothing New
JAMA Network Open
In their article "Assessment of Time-to-Treatment Initiation and Survival in a Cohort of Patients with Common Cancers," Cone et al 1 bring to the forefront an important and topical issue about the risks of delays in cancer care. They focus on delays in time-to-treatment initiation (TTI) with curative-intent therapy following diagnosis in a retrospective cohort study leveraging the National Cancer Database for nonmetastatic prostate, breast, and colon, and stages I and II lung cancer treated
... cancer treated from 2004 to 2015. They find evidence that longer TTI is associated with higher mortality across cancer types, most significantly in colon cancer and early-stage lung cancer. As the authors note, this study's major limitation is the inability to identify the reason for the treatment delay. For example, close to 90% of included patients with colon cancer received treatment in the reference 8-to-60-day time period from diagnosis. This could suggest that patients experiencing delays in TTI are outliers who are fundamentally different than the underlying cohort and thus not representative. Along with the non-small cell lung cancer subgroup, the colon cancer subgroup also had much higher Charlson Comorbidity index scores compared with the breast and prostate cancer subgroups. And despite incomes being similar across cancers, patients with lung and colon cancer had lower rates of private insurance, and an outlying 58% of patients with colon cancer had Medicaid insurance. Yet, importantly, the authors also find harms in delay in intermediate-risk and high-risk prostate cancer, despite expert guidance that early treatment is less important and despite lower rates of early treatment across risk stages. This finding mitigates concerns that patients with longer TTI may be outliers physiologically or otherwise. TTI is likely influenced by both medical and social factors that also influence overall survival. Still, while the reason for delay for individual patients in the cohort is unknown, the findings of this study are consistent across the data set, biologically plausible, and worthy of concern. This study also draws attention to the importance of prioritizing timely cancer care, even during the coronavirus disease 2019 (COVID-19) pandemic. In addition to being the most common cancers, breast, colon, prostate, and lung cancer are the cancers most commonly detected via populationwide screening. Although US Preventive Services Task Force guidelines vary across types of cancer and are least prescriptive for prostate cancer, the fundamental purpose of screening is to identify asymptomatic cancers in a timely fashion where earlier diagnosis and treatment are known to improve survival. Decades of research in these diseases have shown that earlier diagnosis is beneficial. A body of research in disparities demonstrates that delays in cancer diagnoses and treatment disproportionally affect racial and ethnic minority populations and the poor, who also experience worse overall and cancer-specific mortality. 2 Primary care, the most important conduit for cancer screening and initial evaluation of new symptoms, has been the hardest hit economically and the most subject to profound disruption and restructuring during the current COVID-19 pandemic. 3 Research by Alexander et al 4 showed an overall decrease of 21.4% in primary care utilization during 2020, with greater decreases in officebased visits, new medication starts, and monitoring of clinical markers like blood pressure and cholesterol. The pandemic may have long-term implications for access to timely care, particularly given existing geographic, racial, and economic disparities in primary care access, as well as the inadequate funding and lower reimbursements that limit new graduates' interest in pursuing the field. Whether for pandemic or financial reasons, patients themselves must frequently weigh the costs and benefits of seeking medical care. They are fundamentally ill equipped to make this decision.