Elsevier

Oral Oncology

Volume 51, Issue 3, March 2015, Pages 272-278
Oral Oncology

Determinants of treatment waiting times for head and neck cancer in the Netherlands and their relation to survival

https://doi.org/10.1016/j.oraloncology.2014.12.003Get rights and content

Summary

Introduction

Waiting to start treatment has been shown to be associated with tumor progression and upstaging in head and neck squamous cell carcinomas (HNSCCs). This diminishes the chance of cure and might lead to unnecessary mortality. We investigated the association between waiting times and survival in the Netherlands and assessed which factors were associated to longer waiting times.

Methods

Patient (age, sex, socioeconomic status (SES), tumor (site, stage) and treatment (type, of institute of diagnosis/treatment) characteristics for patients with HNSCC who underwent treatment were extracted from the Netherlands Cancer Registry (NCR) for 2005–2011. Waiting time was defined as the number of days between histopathological diagnosis and start of treatment. Univariable and multivariable Cox regression was used to evaluate survival.

Results

In total, 13,140 patients were included, who had a median waiting time of 37 days. Patients who were more likely to wait longer were men, patients with a low SES, oropharynx tumors, stage IV tumors, patients to be treated with radiotherapy or chemoradiation, and patients referred for treatment to a Head and Neck Oncology Center (HNOC) from another hospital. The 5-year overall survival was 58% for all patients. Our multivariable Cox regression model showed that longer waiting time, was significantly related to a higher hazard of dying (p < 0.0001).

Conclusion

This is the first large population-based study showing that longer waiting time for surgery, radiotherapy or chemoradiation is a significant negative prognostic factor for HNSCC patients.

Introduction

Waiting times for cancer treatment are a serious challenge for doctors and health care policy makers [1], [2]. The ongoing shift of cancer care towards centralized comprehensive cancer centers that are treating higher patient volumes shows evident improvement of quality of care [3], [4]. However, the increasing volume is imposing a burden on available diagnostic and treatment resources [1], [5]. Encouraged by governments and patient lobbies, fast-track programs are introduced throughout Europe to optimize care pathways and minimize the time for diagnosis, staging and treatment. There is evidence that these programs are reducing total waiting time, though these initiatives are not leading to waiting times that meet current standards set by professional societies and authorities [6], [7], [8], [9], [10], [11].

Longer intervals between the confirmation of a malignant tumor and initial treatment could potentially induce anxiety and lower patient satisfaction [12], [13]. The major concern arises when waiting for treatment causes progression of disease, decreased tumor control, more extensive treatment, increased costs and impaired survival. Several studies explored this relationship in different cancer sites and found a correlation with prognosis in patients with uterine [14], and breast [15] cancer. On the other hand, in colorectal [16] and bladder [17] cancer, there was no or little evidence for this association.

In head and neck cancer, there are no consistent results regarding the relationship of waiting time and survival. A systematic review assessing 4238 patients showed a slight significant decrease in survival associated with longer waiting times for radiotherapy in HNSCC patients [18]. However, a recent study including all types of treatment (N = 2493) in the Netherlands Cancer Institute revealed that there was no relation between waiting time for treatment up to 90 days and impaired survival. In one of the sub-analyses, a poorer survival was found for patients with shortest waiting time (<2 weeks) for treatment, and better survival for patients with moderate or longer waiting time [11]. This can be explained by the ‘waiting time paradox’, as a result of confounding by indication; patients with more advanced, rapidly progressive tumors and more severe symptoms are treated earlier, but have a higher mortality, leading to a U-shaped association between waiting time and survival [19], [20].

In the Netherlands, the total volume of head and neck cancer patients increased with more than 50% from 1,942 in 1989 to 2,970 in 2011 [21]. Care is mainly provided by eight geographically allocated Head and Neck Oncology Centers (HNOCs), certified since 1984 by the Dutch Head and Neck Society (DHNS). In 2001, the DHNS anticipated to the growing number of patients per Center and to assure a high standard of care set the maximum duration between diagnosis and treatment at 30 days [22]. In a recent study, this target was only satisfied for 34% of the head and neck squamous cell carcinoma (HNSCC) patients between 1990 and 2011 [10], [11].

Waiting time for treatment of HNSCC patients in the Netherlands seems to be a major problem; however, at the same time the relevance is unclear since waiting time for treatment has not been established as a prognostic factor. This study was performed to investigate which factors are correlated with longer waiting time for treatment of HNSCCs. Additionally, we examined the impact of waiting on survival in patients with a HNSCC in a nationwide population-based study.

Section snippets

Population

Patients were selected from the Netherlands Cancer Registry (NCR), managed by the Comprehensive Cancer Centre the Netherlands (IKNL). All patients in the Netherlands with newly diagnosed head and neck cancer (ICD-O-3 C00-C14 or C30-C32) [23] diagnosed from 2005 through 2011 (21108 records for 20621 patients) were identified. We excluded non-epithelial tumors (melanoma, sarcoma and hematological malignancies; N = 1800, 9% of all records). Patients who did not undergo treatment, for any reason,

Population characteristics

Table 1 shows the characteristics of the total study population (N = 13,140). Summarizing, the median age for men was 63 (range 10–97) and 63 (range 0–98) for women. Most tumors were found in the oral cavity (33%) and larynx (28%) and diagnosed at Stage I (31%) or Stage IV (36%).

Seventy-nine percent of the patients were treated in one of the eight HNOCs. The average number of patients treated in a HNOC from 2005 through 2011 was 186 per year. This number increased every year from 153 in 2005 to

Discussion

In the Netherlands, waiting times in healthcare is a heavily debated subject since these waiting times rose to an unacceptable level in the 1990s, due to the disincentive for medical specialists and hospitals to increase production as a result of the introduction of fixed budgets and limitation of capacity [27]. In 2001, the Dutch Head and Neck Society wrote a guideline on quality and organization of care that stated that 80% of the head and neck cancer patients should be treated within 30 days

Conclusion

In conclusion, this is the first large population-based study showing that a longer waiting time for surgery, radiotherapy or chemoradiation is a significant negative prognostic factor for HNSCC patients. Besides the negative prognostic impact of longer waiting times, we found a better survival for patients who are treated in a HNOC. We therefore recommend referring cancer patients and patients with suspicious lesions to a specialized Head and Neck Oncology Center as early as possible,

Conflict of interest

This work was financially supported by the Verwelius Foundation and the Stol-Hoeksema family foundation. We have no other financial relationships or conflict of interest to disclose.

Acknowledgements

The authors thank the registration teams of The Comprehensive Cancer Centre Netherlands for the collection of data for the Netherlands Cancer Registry.

We would also like to acknowledge the Verwelius Foundation and Stol-Hoeksema family foundation for supporting this work.

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