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Vets may not get speedy cancer care

By C. E. Huggins

NEW YORK (Reuters Health) - Adults diagnosed with colon or rectal cancer are experiencing longer wait times before receiving cancer treatment in Veterans Affairs (VA) Medical Centers across the U.S., according to a recent report.

The growing treatment delays may not be specific to VA centers alone, and whether the delays are tied to worse outcomes, as previous studies have found for breast and other cancers, is unknown, researchers said.

"Our study identified a trend in increasing wait times at VA hospitals that will most certainly continue in the next decade," lead study author Dr. Ryan P. Merkow told Reuters Health, adding that "large, academic institutions also are dealing with similar issues."

"Nevertheless," he said in an email, "…these are cancer patients, and living and waiting for definitive treatment for a prolonged period can have psychological effects that should not be overlooked."

Dr. Edward Brooks, from the American Cancer Society (ACS), agreed that treatment delays can cause "significant anxiety among patients." He acknowledged, "there should be some degree of concern" about the recent findings. "How much (concern) is not entirely clear," said Brooks, who is director of prostate and colorectal cancers in the Cancer Control Science Department of the ACS but was not involved in the study.

Roughly 3 percent of all cancers in the U.S. are treated in VA Medical Centers. Colon and rectal cancers, which represent 11 percent of all cancers, are the third leading cause of cancer-related death among both men and women, according to ACS.

Deaths from colorectal cancers have declined due to improved screening and treatment, but prior to the current study, there was little research on the amount of time patients waited for treatment after being diagnosed.

To investigate, Merkow, a surgeon at the Northwestern University Feinberg School of Medicine in Chicago, and his colleagues analyzed data from the VA Central Cancer Registry on 17,487 men and women who were treated for colon or rectal cancer in one of four time periods from 1998 to 2008. All of the patients were treated at a VA hospital, although some received their cancer diagnosis elsewhere.

The investigators found that wait times from diagnosis to treatment for both colon and rectal cancers increased throughout the study period. Overall, one in four patients waited 45 or more days before undergoing surgery after receiving a diagnosis of colon cancer, they reported in the August print edition of the Journal of Oncology Practice and online earlier this year.

Half of patients diagnosed with colon cancer in 2007-2008 waited more than 32 days before undergoing surgery, whereas the median wait time was 19 days for those diagnosed in 1998-2000.

Wait times were even longer for patients with rectal cancer, with one quarter of diagnosed patients waiting at least 60 days before receiving either surgery or chemotherapy. Again, increasing wait times were a trend over the years: Slightly more than a third of patients diagnosed in 2007-2008 waited 60 or more days before receiving treatment, whereas only about 15 percent of those diagnosed from 1998 to 2000 waited that long.

One of the factors linked to treatment delays was older age. Adults aged 75 years and older were about 60 percent more likely to experience treatment delays for colon and rectal cancer than were patients under the age of 55.

The location of a patient's diagnosis and treatment also appeared to influence wait times, as those diagnosed and treated at different hospitals were more likely to experience a delay than those who were diagnosed and treated at the same facility.

More advanced disease predicted shorter wait times, though higher surgical volume in hospitals was linked to greater delays in treatment. Marital status was significant only for rectal cancer, with married adults waiting less time for cancer treatment, whereas black race predicted longer wait times for colon cancer.

Whether these extended wait times translated into shorter survival times was not studied. According to Merkow, "there is some data linking increasing wait times to survival for other cancers, however, it is unknown what constitutes a ‘safe' wait time in colorectal cancer."

There are likely multiple factors that explain the increased wait times from diagnosis to treatment, Merkow noted.

"First, the VA population is expanding at a faster rate than many VA hospitals have the resources or capacity to keep up with…. Second, the population is in general aging and Americans are living longer. As a result, we can expect an increase in colorectal cancers diagnosed without an appreciable increase in the number of surgeons treating these patients. Third, cancer care is complex and requires the coordinated efforts of a variety of health care providers. This coordination remains challenging," he said.

"I think a hospital or health system should be interested in its efficiency of care," said Dr. David J. Bentrem, senior author of the study. "Timeliness is one of the six domains of quality healthcare laid out by the Institute of Medicine in their landmark report, Crossing the Quality Chasm," said Bentrem, a professor of surgical oncology at the Feinberg School of Medicine.

Brooks told Reuters Health it is "impossible to say what led to these delays." He speculated that patients may play a part, however, and described scenarios in which some individuals may not be prompt in following through with their treatment after diagnosis, while others may miss appointments and not receive priority rescheduling.

"I think this study hopefully will prompt the VA to step back and start taking a look at this issue," Brooks said.

SOURCE: http://bit.ly/1aQkQGU Journal of Oncology Practice, August 2013.

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