Determinants of treatment waiting times for head and neck cancer in the Netherlands and their relation to survival
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.
References (32)
- et al.
Waiting times for diagnosis and treatment of head and neck cancer in Denmark in Denmark in 2010 compared to 1992 and 2002
Eur J Cancer
(2013) - et al.
The association between referral source and outcome in patients with colorectal cancer
Surgeon: J. Royal Colleges Surgeons Edinburgh Ireland
(2013) - et al.
Cancer Patient Pathways shortens waiting times and accelerates the diagnostic process of suspected sarcoma patients in Denmark
Health Policy
(2013) - et al.
The association of treatment delay and prognosis in head and neck squamous cell carcinoma (HNSCC) patients in a Dutch comprehensive cancer center
Oral Oncol
(2014) - et al.
Psychosocial problems in head-and-neck cancer patients and their change with time since diagnosis
Ann Oncol
(1993) - et al.
Relationship of diagnostic and therapeutic delay with survival in colorectal cancer: a review
Eur J Cancer
(2007) - et al.
The relationship between waiting time for radiotherapy and clinical outcomes: a systematic review of the literature
Radiother Oncol: J Eur Soc Ther Rad Oncol
(2008) - et al.
Diagnostic interval and mortality in colorectal cancer: U-shaped association demonstrated for three different datasets
J Clin Epidemiol
(2012) - et al.
Evidence of increasing mortality with longer diagnostic intervals for five common cancers: a cohort study in primary care
Eur J Cancer
(2013) - et al.
Waiting times for radiotherapy: consequences of volume increase for the TCP in oropharyngeal carcinoma
Radiother Oncol: J Eur Soc Ther Radiol Oncol
(2003)
Tumor progression in waiting time for radiotherapy in head and neck cancer
Radiother Oncol: J Eur Soc Ther Radiol Oncol
Wait times for cancer surgery in the United States: trends and predictors of delays
Ann Surg
A prospective study: current problems in radiotherapy for nasopharyngeal carcinoma in yogyakarta, indonesia
PLoS ONE
Hospital volume and late survival after cancer surgery
Ann Surg
Volume criteria for the treatment of head and neck cancer: are they evidence based?
Head Neck
A snapshot of waiting times for cancer surgery provided by surgeons affiliated with regional cancer centres in Ontario
CMAJ
Cited by (143)
Predictors of prolonged treatment time intervals in oral cavity cancer
2023, Oral OncologyPrognostic significance of time trends in treatment of head and neck squamous cell carcinoma
2023, American Journal of Otolaryngology - Head and Neck Medicine and SurgeryImpact of time-to-surgery on survival and quality of life in oral cancer
2023, American Journal of Otolaryngology - Head and Neck Medicine and Surgery