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Original Research: LUNG CANCER |

Timeliness of Care in Veterans With Non-small Cell Lung Cancer* FREE TO VIEW

Michael K. Gould, MD, MS, FCCP; Sharfun J. Ghaus, MBBS; Julie K. Olsson, MD, MS; Ellen M. Schultz, MS
Author and Funding Information

*From the Veterans Affairs Palo Alto Health Care System (Drs. Gould, Ghaus, and Olsson), Palo Alto, CA; and Stanford School of Medicine (Ms. Schultz), Stanford, CA.

Correspondence to: Michael K. Gould, MD, MS, FCCP, Veterans Affairs Palo Alto Health Care System, 3801 Miranda Ave (111P), Palo Alto, CA 94304; e-mail: gould@stanford.edu



Chest. 2008;133(5):1167-1173. doi:10.1378/chest.07-2654
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Background: Timeliness is an important dimension of quality of care for patients with lung cancer.

Methods: We reviewed the records of consecutive patients in whom non-small cell lung cancer (NSCLC) had been diagnosed between January 1, 2002, and December 31, 2003, at the Veterans Affairs Palo Alto Health Care System. We used multivariable statistical methods to identify independent predictors of timely care and examined the effect of timeliness on survival.

Results: We identified 129 veterans with NSCLC (mean age, 67 years; 98% men; 83% white), most of whom had adenocarcinoma (51%) or squamous cell carcinoma (30%). A minority of patients (18%) presented with a solitary pulmonary nodule (SPN). The median time from the initial suspicion of cancer to treatment was 84 days (interquartile range, 38 to 153 days). Independent predictors of treatment within 84 days included hospitalization within 7 days (odds ratio [OR], 8.2; 95% confidence interval [CI], 2.9 to 23), tumor size of > 3.0 cm (OR, 4.8; 95% CI, 1.8 to 12.4), the presence of additional chest radiographic abnormalities (OR, 3.0; 95% CI, 1.1 to 8.5), and the presence of one or more symptoms suggesting metastasis (OR, 2.6; 95% CI, 1.1 to 6.2). More timely care was not associated with better survival time (adjusted hazard ratio, 1.6; 95% CI, 1.3 to 1.9). However, in patients with SPNs, there was a trend toward better survival time when the time to treatment was < 84 days.

Conclusions: The time to treatment for patients with NSCLC was often longer than recommended. Patients with larger tumors, symptoms, and other chest radiographic abnormalities receive more timely care. In patients with malignant SPNs, survival may be better when treatment is initiated promptly.

Figures in this Article

Timeliness of care is an important dimension of health-care quality.1In patients with lung cancer, timely care is important because delays in diagnosis and treatment contribute to emotional distress, and longer delays might be associated with missed opportunities for cure or effective palliation. Accordingly, the British Thoracic Society recommends2that all patients with suspected lung cancer should be evaluated by a respiratory specialist within 7 days of presentation, and that the results of diagnostic tests should be communicated to the patient within 2 weeks. Furthermore, in published3 quality indicators for lung cancer care, the RAND Corporation (Santa Monica, CA) specified that a diagnosis of lung cancer should be established within 2 months of the initial abnormal chest radiograph findings and that treatment should be offered within 6 weeks of the diagnosis.

Several studies have examined timeliness of care for patients with lung cancer in Europe and Japan,413 but surprisingly few studies of timeliness have been performed in the United States.1417 None of the US studies attempted to identify predictors of timely care, and only one US study15 examined the relationship between timeliness of care and survival. We performed a retrospective cohort study to describe the variation in the timeliness of care in a sample of veterans with lung cancer, to identify predictors of timely care, and to examine the effect of more timely care on survival.

We retrospectively reviewed the electronic medical records of 129 consecutive patients in whom non-small cell lung cancer (NSCLC) had been diagnosed at the Veterans Affairs Palo Alto Health Care System between January 1, 2002, and December 31, 2003. We collected information about patient characteristics, tumor characteristics, symptoms suggestive of metastasis at the time of presentation, the utilization of imaging tests and other procedures, the dates of diagnosis and first treatment, and vital status. The Stanford University institutional review board approved the study and waived the requirement for informed consent.

We considered the date of initial lung cancer suspicion to be the date of the first chest radiograph or chest CT scan that showed an abnormal focal opacity that was later confirmed to be lung cancer. We defined the time to diagnosis as the time interval between the date of initial suspicion and the date on which the diagnosis of lung cancer was confirmed by histopathology. We defined the time to treatment as the time interval between the date of initial suspicion and the date on which treatment was initiated, or (in the case of patients who refused treatment) the date on which treatment refusal was documented in the medical record. We defined a patient with a solitary pulmonary nodule (SPN) as one who had no symptoms at the time of presentation, and a nodule that measured up to 3 cm in diameter and was completely surrounded by aerated lung with no associated atelectasis, hilar enlargement, or pleural effusion.

For continuous variables, we report the mean and SD for normally distributed variables, and the median and interquartile range (IQR) for variables with nonnormal distributions. For categoric variables, we report the frequencies and percentages. For continuous variables, we used an unpaired t test or Mann-Whitney U test to compare groups, as appropriate. For categoric variables, we performed the χ2 test to compare groups. To identify independent predictors of more timely diagnosis and treatment, we dichotomized time intervals and used multiple logistic regression analysis. We report odds ratios (ORs) and 95% confidence intervals (CIs). We also used linear regression analysis in which log-transformed time intervals were the dependent variables.

To examine the association between the timeliness of treatment and survival, we used Cox proportional hazards analysis. We measured survival from the date of the initial radiographic abnormality to the date of death or the date of last contact. To control for the severity of disease and other potential confounders, we included age, gender, race/ethnicity, TNM stage, tumor histology, and type of treatment received in survival models. We considered a p value of < 0.05 to be statistically significant. We performed all analyses with a statistical software package (SPSS, version 14.0 for Windows; SPSS; Chicago, IL).

As shown in Table 1 , most of the patients were white (83%) and men (98%). The mean age was 67 years (SD, 10 years). The median tumor diameter was 3.2 cm (IQR, 2.0 to 5.0 cm). Most of the patients had adenocarcinoma (51%) or squamous cell carcinoma (30%) histology. The TNM stage distribution of patients included 15% in stage I, 14% in stage II, 33% in stage III, and 37% in stage IV. A minority of patients (18%) presented with an SPN.

Time to Diagnosis and Time to Treatment

There was considerable variation in the times to diagnosis and treatment (Fig 1 ). The median time between the initial suspicion of cancer and diagnosis was 42 days (IQR, 11 to 117 days), and the median time between initial suspicion and treatment was 84 days (IQR, 38 to 153 days). The median time from diagnosis to treatment was 22 days (IQR, 8 to 41 days). Seventy-six patients (59%) received diagnoses within 60 days of initial suspicion, and 98 patients (76%) were treated within 6 weeks of receiving a diagnosis. Only 51 patients (40%) received a diagnosis and were treated within the maximum time of 14 weeks that was recommended by the RAND Corporation.3 In the quartile of patients (n = 33) with the longest treatment delays (ie, > 153 days), the most common problems included delays in obtaining a CT scan (n = 18), delays awaiting biopsy or surgery (n = 6), and delays related to transferring care from another facility (n = 6).

Evaluation and Treatment

Nearly all patients underwent chest radiographs (99%) and chest CT scans (98%) during the diagnostic and staging evaluation (Table 2 ). More than one chest radiograph was performed in 30% of patients, more than one CT scan of the chest was performed in 11% of patients, and more than one positron emission tomography scan was performed in 3% of patients. Patients underwent a variety of diagnostic and staging procedures (Table 2), but few underwent multiple procedures, and preoperative invasive staging was uncommon. Six patients (5%) underwent both transthoracic needle aspiration biopsy and bronchoscopy for diagnosis, while five patients (4%) underwent more than one invasive staging procedure. Mediastinoscopy or anterior mediastinotomy was performed in 6% of patients with stage II disease and 14% of patients with stage III disease. Transbronchial needle aspiration was performed in 13% of patients with stage II disease and in 19% of patients with stage III disease. Endoscopic ultrasound was performed in one patient with stage III disease. Age, gender, race/ethnicity, primary tumor size, and the presence of symptoms were not associated with the use of invasive mediastinal biopsy. Patients with centrally located primary tumors (21% vs 6%, respectively; p = 0.02) and spiculated primary tumors (21% vs 5%, respectively; p < 0.05) were more likely to undergo mediastinal biopsy.

Treatment included surgery in 36 patients (28%), external beam radiation in 45 patients (35%), and chemotherapy in 51 patients (45%). Best supportive care was provided in 26 patients (20%).

Clinical Predictors of Timeliness

In bivariate analyses, a shorter time to treatment (ie, less than the median time of 84 days) was seen more frequently in patients with tumor diameters of > 3.0 cm (62% vs 32%, respectively; p = 0.001), in patients with symptoms suggesting metastasis (62% vs 32%, respectively; p = 0.001), in patients with additional abnormalities seen on chest radiography (67% vs 44%, respectively; p = 0.02), and especially in patients who had been admitted to the hospital within 7 days of the initial suspicion of cancer (79% vs 36%, respectively; p < 0.0001). The median time to treatment was significantly longer in patients who had been treated surgically (131 vs 57 days, respectively; p = 0.02). The median time to diagnosis was considerably longer in patients without symptoms (75 vs 23 days, respectively; p = 0.001).

In multiple logistic regression analysis, independent predictors of treatment within 84 days included hospital admission within 7 days (OR, 8.2; 95% CI, 2.9 to 23), tumor size of > 3.0 cm (OR, 4.8; 95% CI, 1.8 to 12.4), the presence of additional radiographic abnormalities (OR, 3.0; 95% CI, 1.1 to 8.5), and the presence of one or more symptoms suggesting metastatic disease (OR, 2.6; 95% CI, 1.1 to 6.2). Independent predictors of diagnosis within 42 days included hospitalization within 7 days (OR, 10.3; 95% CI, 3.5 to 30), tumor size of > 3 cm (OR, 5.5; 95% CI, 2.0 to 15), and white race (OR, 3.0; 95% CI, 1.1 to 8.0).

Effect of Timeliness on Survival

The median follow-up time was 270 days (IQR, 134 to 488 days) from the date of initial suspicion, and 147 days (IQR, 42 to 333 days) from the date of treatment. Eighty-seven patients (67%) died during follow-up, and the median survival time (measured from the date of initial suspicion) was 299 days (IQR, 196 to 402 days). As shown in Figure 2 , patients treated within 84 days of diagnosis were more likely to die during follow-up than patients who were treated less promptly (80% vs 55%, respectively; p = 0.003). Accordingly, the median survival time was shorter in patients who were treated within 84 days after diagnosis (142 vs 535 days, respectively; p < 0.0001). Even after adjusting for age, gender, race/ethnicity, TNM stage, tumor histology, and type of treatment received, the hazard of death was still increased in patients with shorter time (log-transformed days) to treatment (hazard ratio [HR], 1.6; 95% CI, 1.3 to 1.9).

When we stratified the analysis according to severity of disease at the time of presentation, the paradoxical results were no longer seen in the subgroup of patients who presented with solitary nodules (Fig 3 ). In patients with more severe presentations of lung cancer (n = 106), the median survival time was still shorter in those who were treated more promptly (137 vs 467 days, respectively; p = 0.001). However, in the group of patients with SPNs, the 2-year cumulative survival rate was 100% in 5 patients treated within 84 days vs about 65% in 18 patients with longer treatment delays (p = 0.13 [Pearson χ2 test]; p = 0.22 [log rank test]).

Timeliness of care is one of six important dimensions of health-care quality, as defined by the Institute of Medicine.1 In this sample of veterans with lung cancer, we found that times to diagnosis and treatment were often longer than the current recommendations dictate. The time to diagnosis was > 2 months (the threshold recommended by the RAND Corporation3) in 40% of patients, and the time from diagnosis to treatment was > 6 weeks in 24% of patients. Clinical factors associated with more timely diagnosis included larger tumor size, hospitalization within 7 days of initial cancer suspicion, and white race. Factors associated with shorter times from the initial suspicion to the start of treatment included larger tumor size, hospitalization within 7 days, symptoms suggestive of metastasis, and radiographic abnormalities, such as postobstructive pneumonia and pleural effusion. The time to treatment was longer in patients treated surgically. Paradoxically, we found that overall survival times were worse in patients with shorter times to treatment. When we examined the subgroup of patients with malignant SPNs, we found a trend toward improved survival time with more timely treatment, although this result was not statistically significant. While preliminary, these results suggest that timeliness of treatment may affect survival time in some patients, but not in all patients with lung cancer, which highlights the importance of controlling for disease severity at the time of presentation. Further research is needed to explore the association between timeliness of care and survival time in patients with malignant SPNs, compared to patients with more advanced disease.

Multiple studies1417 have examined the timeliness of care in patients with lung cancer, but few studies were performed in the United States. The majority of studies were performed in Europe, Canada, and Japan. In these studies, the median time to diagnosis ranged from 8 to 52 days, and the median time from diagnosis to treatment ranged between 12 and 52 days.4,8,14,1826 The median times to diagnosis and treatment in our study fell within these ranges.

Few published studies have attempted to identify patient characteristics that predict more timely care. In two studies2728 conducted in primary care settings, the presence of respiratory symptoms was associated with more timely imaging and specialist referral. In two other studies,13,26 the presence of at least one comorbid condition was associated with longer times to surgery. While several studies21,23,26,29 have reported that age was not associated with delays in diagnosis or treatment, two studies13,24 in surgical patients reported conflicting results. In other studies,13,21,2324,2930 there was no association between timeliness of treatment and gender or place of residence. To our knowledge, no prior study has examined race as a determinant of timeliness of treatment.

A small number of studies have examined the relationship between the timeliness of treatment and survival, and the results of these studies have been mixed. Two Japanese studies9,31 have reported worse survival times in patients who experienced longer delays in diagnosis after suspicious nodules were detected by lung cancer screening. In one study,9 the median survival time was approximately 35 months for patients with diagnostic delays of < 4 months, compared with 20 months for patients with longer delays. Likewise, another study31 found that, after adjusting for age, gender, histology, stage, and treatment, the hazard of death was twice as high in patients who had a 1 year delay in diagnosis because the radiographic abnormality was seen only in retrospect. These studies are limited by small sample sizes, arbitrary cut points for defining delayed diagnosis, and the possibility of lead-time bias, as the authors did not specify the point in time from which survival was measured. Another uncontrolled study12 from Scotland examined the effect of diagnosis delay on tumor growth. In this study, the median time between a diagnostic CT scan and a follow-up CT scan for radiotherapy planning was 54 days (range, 18 to 131 days). During this time interval, the median tumor cross-sectional diameter increased by 19% (range, 0 to 373%).

Four studies45,15,32 of patients with surgically treated lung cancer reported no association between waiting times of different types and survival. In the only US study, Quarterman et al15 retrospectively reviewed the records of 83 veterans who underwent resection for stage I or stage II NSCLC at the San Francisco Veterans Affairs Hospital between 1989 and 1999. In this study, the median time from initial contact to surgical treatment was 82 days. In an unadjusted analysis, there was no difference in the hazard of death for patients who did and did not experience treatment delays that were > 90 days (HR, 1.06; 95% CI, 0.87 to 1.3). This study, like the other three studies in this group, is confounded by the exclusion of nonsurgical patients. It is possible that some patients were excluded from the study because they had long wait times and therefore had disease that progressed to a stage that was not treatable by surgery. In addition, these studies did not control fully for other factors that might confound the relationship between timeliness and survival, such as tumor size and the severity of disease at the time of presentation.

One study29 from Sweden examined timeliness of diagnosis and survival in a relatively large (n = 466) and heterogeneous cohort of patients with NSCLC. In this study, the median time from symptom onset to treatment was 4.6 months, and the median time from hospitalization to treatment was 1.6 months. Predictors of longer times from hospitalization to treatment included older age, less advanced TNM stage, and surgical treatment. In bivariate survival models, longer times from symptom onset to treatment, and from hospitalization to treatment, were associated with a reduced hazard of death. Even after adjusting for age, gender, tumor histology, TNM stage, and surgical treatment, the hazard of death was still lower in patients with longer intervals between symptom onset and treatment (adjusted HR, 0.80; 95% CI, 0.6 to 1.0). Our results were even more extreme, as the adjusted hazard of death was 60% greater in our patients with shorter times to treatment.

The paradoxical results of these studies are most likely due to selection bias. Specifically, patients with more severe symptoms and signs are more likely to receive diagnoses and treatment relatively quickly, and then promptly die despite receiving timely care. For example, a patient with a large primary tumor and spinal cord compression from vertebral body metastasis is much more likely to receive a diagnosis and be treated promptly than an asymptomatic patient with a malignant pulmonary nodule.

Our study has several limitations, including the relatively small size of the sample and the retrospective design. Because we examined care provided at a single Veterans Affairs facility, the results may not be generalizable to other US health-care settings. However, in one of the two US studies17 performed in a non-Veterans Affairs setting, the mean time from diagnosis to treatment in a large cohort of Hawaiian lung cancer patients was 28 days, approximately 1 week longer than we reported. The results were similar in the only other non-Veterans Affairs study,16 which compared the timeliness of care received by Asian and non-Asian lung cancer patients in Boston. In addition, the single-center design precluded us from examining the influence of hospital characteristics on the timeliness of care. Finally, some patients with small or benign-appearing lesions may have been managed by “watchful waiting,” intentionally prolonging the time to diagnosis. On the other hand, this study addresses an important question and avoided selection bias by including a consecutive sample of unselected lung cancer patients. Through a review of patients’ medical records, we were able to objectively measure time intervals and collect detailed clinical information. To our knowledge, we are the first group to identify racial disparity in the timeliness of lung cancer care, as the odds of receiving a more timely diagnosis were three times greater in whites than nonwhites.

Our finding that more timely treatment appears to be associated with better survival time in lung cancer patients who present with an SPN should be interpreted cautiously. First, because of the small numbers of patients, the results are not statistically stable. In addition, it is possible that sicker patients with comorbid conditions required more extensive preoperative evaluations, and this could confound the relationship between timeliness and survival. Nevertheless, because the survival time is extremely poor in patients with advanced lung cancer (with or without timely care), patients who present with less advanced disease may have the most to gain from future quality improvement efforts.

Patients with known or suspected lung cancer and their family members should expect prompt diagnosis and treatment once they have made contact with the health-care system. Our results suggest that there is considerable room for improvement. Health-care systems and clinicians in the United States should examine the efficiency of their practices for lung cancer care and strive for continuous improvement. Additional research is needed to identify structures and processes of care that are associated with timeliness of care in patients with lung cancer. Quality improvement efforts should be designed to improve the timeliness of lung cancer care without compromising other dimensions of health-care quality.

Abbreviations: CI = confidence interval; HR = hazard ratio; IQR = interquartile range; NSCLC = non-small cell lung cancer; OR = odds ratio; SPN = solitary pulmonary nodule

This work was performed at the Veterans Affairs Palo Alto Health Care System. The opinions expressed are those of the authors and not necessarily those of the Department of Veterans Affairs.

The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Table Graphic Jump Location
Table 1. Demographic and Clinical Characteristics*
* 

Values given as the mean ± SD, %, or median (IQR).

 

Other symptoms included headache, mental status change, visual disturbance, focal weakness or sensory loss, facial swelling, hoarseness, nausea or vomiting, and abdominal bloating or distension.

Figure Jump LinkFigure 1. Box plots showing variations in time to diagnosis, time to treatment, and time between diagnosis and treatment (measured in days). The times to diagnosis and treatment were measured from the date of the initial suspicious chest radiograph or CT scan. In each plot, the heavy horizontal bar represents the median value, the box represents the IQR, and the whiskers represent values up to 1.5 IQRs. Outliers and more extreme values are indicated by circles and asterisks, respectively. Median times to diagnosis, treatment, and between diagnosis and treatment were 42, 84, and 22 days, respectively.Grahic Jump Location
Table Graphic Jump Location
Table 2. Diagnostic and Staging Evaluation
* 

PET = positron emission tomography.

Figure Jump LinkFigure 2. Kaplan-Meier survival curves for patients who were (bottom solid line) and were not (top dotted line) treated within 84 days of the initial suspicion of lung cancer. Date of initial suspicion was defined as the date of first abnormal chest radiograph or CT scan. Last contact was the date of the most recent contact with the patient, as documented in the medical record at the time of chart review. Censored patients are denoted by an “x.” Paradoxically, survival time was better in patients who received less timely care (p < 0.0001).Grahic Jump Location
Figure Jump LinkFigure 3. Kaplan-Meier survival curves for patients who presented with an SPN (right) or a more advanced stage of lung cancer (left). In patients with more advanced cancer, survival time was better in patients who received less timely care. In patients with an SPN, there was a trend toward better survival times in patients who received more timely care (p = 0.22). See the legend of Figure 2 for explanation of terms not defined in the text.Grahic Jump Location
. Institute of Medicine, Committee on Quality of Health Care in America. (2001)Crossing the quality chasm: a new health system for the 21st Century. National Academies Press. Washington, DC:
 
Lung Cancer Working Party of the British Thoracic Society Standards of Care Committee.. BTS recommendations to respiratory physicians for organising the care of patients with lung cancer.Thorax1998;53(suppl),S1-S8
 
Reifel, JL Lung cancer. Asch, SM Kerr, EA Hamilton, EGet al eds. Quality of care for oncologic conditions and HIV: a review of the literature and quality indicators. 2000; RAND Corporation. Santa Monica, CA:.
 
Aragoneses, FG, Moreno, N, Leon, P, et al Influence of delays on survival in the surgical treatment of bronchogenic carcinoma.Lung Cancer2002;36,59-63. [PubMed] [CrossRef]
 
Billing, JS, Wells, FC Delays in the diagnosis and surgical treatment of lung cancer.Thorax1996;51,903-906. [PubMed]
 
Bozcuk, H, Martin, C Does treatment delay affect survival in non-small cell lung cancer? A retrospective analysis from a single UK centre.Lung Cancer2001;34,243-252. [PubMed]
 
Christensen, ED, Harvald, T, Jendresen, M, et al The impact of delayed diagnosis of lung cancer on the stage at the time of operation.Eur J Cardiothorac Surg1997;12,880-884. [PubMed]
 
Dische, S, Gibson, D, Parmar, M, et al Time course from first symptom to treatment in patients with non-small cell lung cancer referred for radiotherapy: a report by the CHART Steering Committee.Thorax1996;51,1262-1265. [PubMed]
 
Kanashiki, M, Satoh, H, Ishikawa, H, et al Time from finding abnormality on mass-screening to final diagnosis of lung cancer.Oncol Rep2003;10,649-652. [PubMed]
 
Koyi, H, Hillerdal, G, Branden, E Patient’s and doctors’ delays in the diagnosis of chest tumors.Lung Cancer2002;35,53-57. [PubMed]
 
Laroche, C, Wells, F, Coulden, R, et al Improving surgical resection rate in lung cancer.Thorax1998;53,445-449. [PubMed]
 
O'Rourke, N, Edwards, R Lung cancer treatment waiting times and tumour growth.Clin Oncol (R Coll Radiol)2000;12,141-144. [PubMed]
 
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Riedel, RF, Wang, X, McCormack, M, et al Impact of a multidisciplinary thoracic oncology clinic on the timeliness of care.J Thorac Oncol2006;1,692-696. [PubMed]
 
Quarterman, RL, McMillan, A, Ratcliffe, MB, et al Effect of preoperative delay on prognosis for patients with early stage non-small cell lung cancer.J Thorac Cardiovasc Surg2003;125,108-113. [PubMed]
 
Finlay, GA, Joseph, B, Rodrigues, CR, et al Advanced presentation of lung cancer in Asian immigrants: a case-control study.Chest2002;122,1938-1943. [PubMed]
 
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Figures

Figure Jump LinkFigure 1. Box plots showing variations in time to diagnosis, time to treatment, and time between diagnosis and treatment (measured in days). The times to diagnosis and treatment were measured from the date of the initial suspicious chest radiograph or CT scan. In each plot, the heavy horizontal bar represents the median value, the box represents the IQR, and the whiskers represent values up to 1.5 IQRs. Outliers and more extreme values are indicated by circles and asterisks, respectively. Median times to diagnosis, treatment, and between diagnosis and treatment were 42, 84, and 22 days, respectively.Grahic Jump Location
Figure Jump LinkFigure 2. Kaplan-Meier survival curves for patients who were (bottom solid line) and were not (top dotted line) treated within 84 days of the initial suspicion of lung cancer. Date of initial suspicion was defined as the date of first abnormal chest radiograph or CT scan. Last contact was the date of the most recent contact with the patient, as documented in the medical record at the time of chart review. Censored patients are denoted by an “x.” Paradoxically, survival time was better in patients who received less timely care (p < 0.0001).Grahic Jump Location
Figure Jump LinkFigure 3. Kaplan-Meier survival curves for patients who presented with an SPN (right) or a more advanced stage of lung cancer (left). In patients with more advanced cancer, survival time was better in patients who received less timely care. In patients with an SPN, there was a trend toward better survival times in patients who received more timely care (p = 0.22). See the legend of Figure 2 for explanation of terms not defined in the text.Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1. Demographic and Clinical Characteristics*
* 

Values given as the mean ± SD, %, or median (IQR).

 

Other symptoms included headache, mental status change, visual disturbance, focal weakness or sensory loss, facial swelling, hoarseness, nausea or vomiting, and abdominal bloating or distension.

Table Graphic Jump Location
Table 2. Diagnostic and Staging Evaluation
* 

PET = positron emission tomography.

References

. Institute of Medicine, Committee on Quality of Health Care in America. (2001)Crossing the quality chasm: a new health system for the 21st Century. National Academies Press. Washington, DC:
 
Lung Cancer Working Party of the British Thoracic Society Standards of Care Committee.. BTS recommendations to respiratory physicians for organising the care of patients with lung cancer.Thorax1998;53(suppl),S1-S8
 
Reifel, JL Lung cancer. Asch, SM Kerr, EA Hamilton, EGet al eds. Quality of care for oncologic conditions and HIV: a review of the literature and quality indicators. 2000; RAND Corporation. Santa Monica, CA:.
 
Aragoneses, FG, Moreno, N, Leon, P, et al Influence of delays on survival in the surgical treatment of bronchogenic carcinoma.Lung Cancer2002;36,59-63. [PubMed] [CrossRef]
 
Billing, JS, Wells, FC Delays in the diagnosis and surgical treatment of lung cancer.Thorax1996;51,903-906. [PubMed]
 
Bozcuk, H, Martin, C Does treatment delay affect survival in non-small cell lung cancer? A retrospective analysis from a single UK centre.Lung Cancer2001;34,243-252. [PubMed]
 
Christensen, ED, Harvald, T, Jendresen, M, et al The impact of delayed diagnosis of lung cancer on the stage at the time of operation.Eur J Cardiothorac Surg1997;12,880-884. [PubMed]
 
Dische, S, Gibson, D, Parmar, M, et al Time course from first symptom to treatment in patients with non-small cell lung cancer referred for radiotherapy: a report by the CHART Steering Committee.Thorax1996;51,1262-1265. [PubMed]
 
Kanashiki, M, Satoh, H, Ishikawa, H, et al Time from finding abnormality on mass-screening to final diagnosis of lung cancer.Oncol Rep2003;10,649-652. [PubMed]
 
Koyi, H, Hillerdal, G, Branden, E Patient’s and doctors’ delays in the diagnosis of chest tumors.Lung Cancer2002;35,53-57. [PubMed]
 
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