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Increasing Time to Initiating Cancer Therapy and Worsened Survival in Curative Settings: A US Analysis of Common Solid Tumors
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Dr. Alok Khorana discusses Increasing Time to Initiating Cancer Therapy and Worsened Survival in Curative Settings: A US Analysis of Common Solid Tumors at ASCO 2017. For the ability to view on your mobile phone please visit us at

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Hi, I'm Alok Khorana. I'm a medical oncologist and director of the GI cancer program at the Taussig Cancer Institute of the Cleveland Clinic. Today I'll be discussing our abstract presented at ASCO 2017 regarding time to treatment initiation for common solid tumors and analysis of US rates and association with outcomes. As background, as many of us who take care of patients know, starting treatment is getting increasingly complicated because of requirement for prior authorizations, looking at staging processes, and so on. Physicians often reassure patients that delays in treatment may be cumbersome, but do not directly impact cancer outcomes. However this is not clear that it is entirely true. Published data are conflicting. Some data suggests that delaying cancer treatment by a few weeks does not impact survival, whereas other data suggests that it may impact survival.

The objectives of our analysis were to investigate trends in time to treatment initiation for common solid tumors treated with curative intent. We decided to focus on early stage cancers because clearly, impact on survival would be more dramatic here. We wanted to identify the determinants of delayed time to treatment initiation as well as to determine the relationship between time to treatment initiation and overall survival. We utilized prospectively collected data of the National Cancer Database, which is one of the largest prospective databases in the United States. We focused on six common solid tumors, the four most common breast cancer, prostate cancer, colorectal and lung cancer and in addition, two less common cancers that have an impact on cancer-related mortality, kidney and pancreas cancers.

Overall, our study population comprised nearly 3.5 million patients. As we had expected, being in clinical practice we know from personal experience the time to treatment initiation is getting worse over time and in fact we found that median time to treatment initiation increased from 21 days in 2004 to 29 days in 2013, which was the last year of analysis and that increase was true across all different types of cancers studied and is shown in figure one. The predictors of delayed time to treatment initiation in multi-rate analysis were unique to some cancers but were all a lot of factors that were common to several cancers. These included the presence of significant comorbidities, transition of care from one facility to another, a prior history of cancer. Surprisingly, care at an academic center increased time to treatment initiation.

Table one shows the association of delayed time to treatment initiation with overall survival which was one of the major objectives of our study. Here we found that even slight delays in treatment, here the hazard ratio is shown, are by week of delay in time to treatment initiation were in fact, associated with increases of mortality across nearly all the cancer studied, the big exception being prostate cancer and most of all the stages studied. So stage one and two breast cancer, kidney cancer, pancreas cancer, lung cancer, and stage two colorectal cancer. All of these cancers and specific stages were associated with an increase in risk of mortality with every week of delay of treatment initiation. The hazard ratio seems small because we are only looking at per week delay in risk of mortality, so a different way to look at this would be to say, hey what happens to cancer patients for starting treatment six weeks after diagnosis versus, let's say three weeks after diagnosis.

Those figures, some representative figures are displayed as curves here. As you can see for both stage one and two lung cancer, as well as stage one and two pancreatic cancer, there are substantial absolute increase risk of mortality for patients who had time to treatment initiation longer than six weeks, versus less than six weeks. Our findings represent a very comprehensive analysis of one of the largest databases prospectively collected of cancer patients with six common solid tumors initiating treatment in the United States. We find the time to treatment initiation has delayed significantly from a median of 21 days at the start of study to a median of 29 days in the most recent year, which is 2013 and this is concerning for patients as well as for physicians.

In addition, and even more importantly, we find that delays in time to treatment initiation in these highly curative settings are associated with the worsened outcomes, especially overall survival in this population. We believe that public health authorities, health systems and insurers need to come together to help identify the causes of delays in time to treatment and attempt to reduce those causes so that we can improve outcomes for you as cancer patients. Thank you for your attention.