The waiting time paradox: population based retrospective study of treatment delay and survival of women with endometrial cancer in Scotland

Abstract

Delay in the delivery of treatment for gynaecological cancers has been previously investigated.1 2 In some cases, the delay reflects the illness behaviour of women; in others, it was inherent in the system for delivering health care. Few studies have linked delay in treatment with survival, although a study from Israel found that survival from endometrial cancer was not affected by a delay in treatment of four months. 3 We investigated links between delays in treatment and survival, using a recently completed audit of endometrial cancer treatment in Scotland. Methods and resultsWe collected data from the case notes of all women resident in Scotland who were diagnosed between 1 January 1996 and 31 December 1997 as having endometrial carcinoma. Of 781 cases, we found case notes for 714, and, out of these, we analysed the 703 cases that involved operative treatment.We calculated time intervals from the dates of general practitioner referral letters, clinic appointments, investigations, and operations. We allocated an International Federation of Gynaecology and Obstetrics (FIGO) stage to each case retrospectively 4 ; we then categorised cases by FIGO stage. 5 We linked these data to survival information from ISD-Scotland and did a univariate analysis using the Kaplan-Meier method and multivariate analysis using Cox's proportional hazards analysis.Delay and survival were inversely related: women with the shortest delay had more advanced disease and survival was least likely for these patients (table). This trend is seen most starkly in the delay from general practitioner referral to first hospital visit.The median interval from referral to definitive operation was 62 days (90th centile 150 days). Large variations between health board areas existed: the median interval from referral to definitive operation varied from 46 to 81 days (74 to 287 days). CommentThe interaction between survival and delay in treatment is complex: we found that patients who experience the longest delay in treatment are more likely to survive. This is paradoxical: it is popularly assumed that delay has a significant and harmful impact on survival.This interaction is partially accounted for by the relation between stage and delay but is only partly explained by the FIGO stage category in a Cox proportional hazards model corrected for age, stage, and use of radiotherapy.The traditional view is that delay caused by organisational defects has an adverse effect on the disease: this influences survival. Our study suggests that disease influences delay, and so delay is a confounding factor.The fact that the strongest effect between delay and survival is seen in the interval between referral and the first hospital visit suggests that general practitioners communicate information related to presentation in some way to consultants. This communication ensures that consultants respond faster to patients who are at higher risk. Consultants seem to be able, from first clinic visit, to differentiate patients at greater risk and to ensure that cancer is diagn...

Prognostic implications of emergency admission and delays in patients with breast cancer

“…Furthermore, in a previous work, Symonds et al [12] reported that cell proliferation rather than late diagnosis was responsible for advance stage in cervical cancers. This inverse correlation of diagnostic delay with survival has been reported previously in breast and lung tumors [1,5]. This probably means that sicker patients are likely to be given priority.…”

The expanding role of primary care in cancer control

“…By contrast, other studies 92,93 have associated prolonged diagnostic intervals with improved survival, a counterintuitive fi nding known as the waiting time paradox, for which two explanations have been proposed. First, aggressive disease might be easier to appraise than mild disease, leading to shorter diagnostic intervals, but is associated with inherent increased mortality.…”

The Association Between Body Mass Index and Presenting Symptoms in African American Women with Ovarian Cancer

“…This finding is consistent with other studies which reported that a more advanced cancer stage was not associated with longer symptom duration, a phenomenon referred to as the ''waiting time paradox.'' 10,12,[23][24][25] Patients with aggressive cancers may show symptoms faster and have more rapid physical decline, leading them to seek medical treatment sooner.…”

“…23 This may have important ramifications as a higher quality of life score has been reported to be an independent prognostic factor in women with ovarian cancer; improved baseline quality of life scores are associated with increased progression-free survival as well as overall survival. 25 Therefore, earlier diagnosis and shorter duration of undiagnosed symptoms may have unrecognized implications and benefits for these patients.…”