In less than half of the patients with head and neck cancer, treatment can be started within the 30 days after arrival at a head and neck center set by the SONCOS standard. This is apparent from the dissertation by Rosanne Schoonbeek (UMCG), in which she used data from the Dutch Cancer Registry, among other things. Schoonbeek investigated which factors contribute to extra waiting time and what the effects are of that extra delay. It turns out that delay does not lead to poorer survival. Schoonbeek: ‘It is valuable to know that a longer waiting time does not lead to a worse outcome in all endpoints, because sometimes more time is simply needed.’
Patients treated with radiotherapy and patients with stage IV tumors often experience delays in their oncological care path, says Schoonbeek. ‘There is a little bit of overlap between the two groups, because people with a higher-stage tumor are often irradiated,’ says Schoonbeek. ‘Irradiation requires a lot of preparation, because you have to make a mask and possibly pull the patient’s teeth. That could explain the delay.’ She adds: ‘A surgical procedure, especially for larger tumors, also requires preparation, but our study showed that this did not cause any delay. What we couldn’t demonstrate, but what we do think is a factor, is a little bit of a delay in referring to the radiation oncologist. In the UMCG, for example, a patient is always the first to return to the surgeon for a consultation after the multidisciplinary consultation (MDO).’
Another factor contributing to a delay in waiting time is chance findings. Schoonbeek: For example, you make a scan of the head because you want to know how big a tumor is. And sometimes you find an aneurysm; you have to do something with that,’ says Schoonbeek. In one in 5 patients a coincidence finding is found that requires further action. Schoonbeek: ‘Then there will be an extra scan, for example. Such patients also had a longer waiting time before they could start treatment.’
Effect of the corona pandemic on waiting times
The COVID-19 pandemic broke out during Schoonbeek’s PhD trajectory. “The pandemic had and still has a huge impact on the healthcare system. But it also gave me the opportunity to see what the impact of the COVID-19 pandemic was on the care of head and neck cancer patients in the Netherlands.’ Schoonbeek did this on the basis of data from the Dutch Cancer Registry (NKR). The incidence of head and neck cancer was almost 25% lower in the first wave of the pandemic compared to the average incidence in 2018 and 2019. ‘But we found no shift in tumor stage or change in treatment,’ Schoonbeek says. And during the pandemic, the median patient turnaround time decreased from 31 days before the COVID-19 pandemic to 26 days during the COVID-19 pandemic. Despite the pressure on the healthcare system, standard treatments for patients with head and neck cancer could be provided with a shorter turnaround time. This shows that shorter lead times are possible in the Dutch head and neck centers.’
The corona pandemic showed that shorter waiting times in Dutch head and neck centers are possible.
Effects of longer waiting time
Schoonbeek: ‘We saw that patients did not experience a lower quality of life, nor did they have a worse 2-year survival, despite a longer waiting time. The latter was also confirmed in the international literature: patients only had a worse survival around 60-70 days of waiting time.’ A longer waiting time in the Netherlands means on average about 40 days, instead of the 30 that is aimed for. Also, Schoonbeek saw no relationship between longer waiting times and postoperative complications or acute radiotherapy-induced toxicity. ‘I therefore wonder whether that cut-off point of 30 days actually leads to an improvement in quality of life or survival, but to determine this, more research is needed in larger cohorts. For example with the data from the NKR.’
Longer waiting times did have an effect on the length of stay for patients, says Schoonbeek. ‘That was striking: patients who have to wait longer for treatment end up in hospital longer, more than 14 days. For older patients in particular, the amount of time that can be spent at home rather than in the hospital is important. So that’s something to keep in mind.’ This is the first time that this relationship has been described in head and neck cancer. ‘It also appeared that older patients who receive primary surgical treatment have a greater chance of a recurrence within 2 years if they have to wait longer until the start of the treatment.’
Short waiting time when possible, longer waiting time if necessary
‘It is important to gain insight into the bottlenecks in the care path for head and neck cancer, in order to prevent unnecessarily longer waiting times,’ says Schoonbeek. ‘Solutions can be relatively simple logistical changes, such as ensuring that radiotherapist and surgeon are both present at the patient consultation after an MDO to discuss the treatment plan. Other aspects lie in the organization of care and cooperation in networks.’ On the other hand, Schoonbeek believes it is important that the target value for head and neck patients is scientifically substantiated. ‘Now the cut-off point of 30 days applies to all head and neck patients. That feels artificial. Isn’t it perhaps more logical to determine a maximum waiting time specifically for tumors? Or treatment dependent, as happened in Denmark?’
What Schoonbeek wants to pass on to colleagues in the head and neck centers: ‘We don’t have to panic immediately if the target value of 30 days is exceeded.’ Sometimes it is better to postpone treatment because additional research is needed, or because the process of joint decision-making takes more time, says Schoonbeek. ‘A surgery in the head and neck area can have a huge impact on the patient; it is logical that the patient and their relatives then need time to think. The benefits of extra time then outweigh the possible consequences of longer waiting times.’
We don’t have to panic immediately if the target value of 30 days is exceeded. Sometimes it just takes more time.
More information
Rosanne Schoonbeek will receive her PhD on 28 September at the University of Groningen/UMCG for her dissertation ‘Delayed Treatment Initiation in the Head and Neck Cancer Care Trajectory’.