A systematic review and meta-analysis in the BMJ showed that even a month’s delay in needed cancer treatment increased the risk of death by 6% to 13%, a risk that increased the longer treatment was put off.
Timothy P. Hanna, MD, MSc, PhD, FRCPC, from the Division of Cancer Care and Epidemiology, Cancer Research Institute at Queen’s University, Kingston, Ontario, and colleagues looked at what impact delaying curative treatment (surgery, systemic treatment, and radiotherapy) would have on mortality for seven major tumor types — bladder, breast, colon, rectum, lung, cervix, and head and neck, which represent 44% of all incident cancers worldwide.
The researchers focused on the question of the effect of treatment delays on cancer outcomes. They also noted that their findings are “timely in light of the current Covid-19 pandemic… Internationally, some countries have released national guidance on prioritization of surgical treatments for cancer, which do not appear to be supported by the results of this study. For example, at the beginning of the pandemic the UK NHS59 created a short-term surgical prioritization algorithm. Several indications were considered safe to be delayed by 10-12 weeks with no predicted impact on outcome, including all colorectal surgery. Therefore, our results can help to directly inform policy—we found that increasing the wait to surgery from six weeks to 12 weeks would increase the risk of death in this setting by 9%.”
The Covid-19 pandemic is impacting patient care in a number of ways, not the least of which is patients putting off needed treatment. The pandemic’s impact was the subject of a recent podcast, Special Considerations in Clinical Oncology and Covid-19.
Hanna and colleagues undertook their review, which included patients of all ages in the seven cancer types. They culled data from Medline from Jan. 1, 2000 through April 10, 2020. Overall, they found 34 studies for 17 indications — curative, neoadjuvant, and adjuvant (n=1,272,681 patients) — and the main outcome measure they were looking at was the “hazard ratio for overall survival for each four-week delay for each indication.” This was measured from time of diagnosis to first treatment or from completion of one treatment to another.
“The association between delay and increased mortality was significant (P<0.05) for 13 of 17 indications,” Hanna and colleagues noted. Among their findings:
- Deaths would increase 6%-8% for every 4 weeks surgery is delayed. For example: HR for each 4-week delay in head and neck surgery 1.06 (95% CI 1.04-1.08) and for breast partial or complete mastectomy HR 1.08 (95% CI 103-1.13). For lung cancer the results consistent with other sites (HR 1.06, 0.93-1.19).
- For systemic treatment the HR was varied (1.01-1.28).
- Adjuvant radiotherapy after breast conserving surgery (HR 0.98, CI 0.88 to 1.09), and for cervix cancer (HR 1.23, CI 1.00 to 1.50).
- Delay in radiotherapy or systemic treatment would result in a “9%-13% increased risk of death for head and neck radiotherapy and adjuvant systemic treatment for colorectal cancer respectively.”
“Delays of up to 8 weeks and 12 weeks further increase the risk of death,” Hanna and colleague wrote. “For example, an eight-week delay in breast cancer surgery would increase the risk of death by 17% (=1.088weeks/4weeks) and a 12 week delay would increase the risk by 26% (=1.0812weeks/4weeks). Such figures translate into significant population level excess mortality. A surgical delay of 12 weeks for all patients with breast cancer for a year (e.g., during Covid-19 lockdown and recovery) would lead to 1,400 excess deaths in the United Kingdom, 6,100 in the United States, 700 in Canada, and 500 in Australia, assuming surgery is the first treatment in 83%, and mortality without delay is 12%.”
Hanna and colleagues called their results “sobering.”
“Taken as a whole, these results suggest there is an urgent need to reconsider how we organize our cancer services,” they wrote. The prevailing paradigm has been around access to new treatments to improve outcomes, but from a system level, gains in survival might be achieved by prioritizing efforts to minimize the time from cancer diagnosis to initiation of treatment from weeks to days.”
Limitations of their study include its design and the risk of residual confounding, for example some patients may have had treatment delays due to other reasons that would adversely affect their outcomes and the findings may not be generalizable.
A systematic review and meta-analysis showed that even a month’s delay in needed cancer treatment increased the risk of death by 6% to 13%, a risk which increased the longer treatment was put off.
The study looked at the impact delaying curative treatment (surgery, systemic treatment, and radiotherapy) would have on mortality for seven major tumor types — bladder, breast, colon, rectum, lung, cervix, and head and neck, which represent 44% of all incident cancers worldwide.
Candace Hoffmann, Managing Editor, BreakingMED™
The study authors declared no relevant relationships.
Cat ID: 935
Topic ID: 78,935,935,151,928,925,934