Canadians Wait Longer for Radiotherapy Than US Patients

SAN FRANCISCO--Delays for radiation treatment are longer in Ontariothan in the United States, Canadian researchers reported in aposter presentation at the annual meeting of the American Societyof Therapeutic Radiology and Oncology (ASTRO).

Of 96 radiation oncology departments from Canada and the UnitedStates surveyed, 89 responded to the study's six case descriptionsand questions regarding waiting times. The results showed thatmedian delays from referral to radiation treatment were significantlylonger in Canada than in the United States for all cases exceptspinal cord compression, the Ontario group reported.

For example, median waiting times for T2N0M0 larynx cancer were29 days in Canada and 10 days in the United States; for painfulbone metastases, 17 days in Canada and 5 days in the United States.All departments in both countries treated patients with spinalcord compression on the day of referral.

"Professional staff in Canada carry higher case loads thantheir counterparts in the US, and equipment utilization is higher,"the researchers said. "But the majority of Canadian cancercenters are unable to treat patients without delays which mostradiation oncologists in the United States and Canada believeare medically unacceptable. Few American centers experience similarproblems."

Waits Getting Longer

An earlier study from the Ontario group showed that waiting listsfor radiotherapy are growing longer in Ontario, with steady deteriorationof access seen between 1982 and 1991.

"Waiting times for radiation treatment have more than doubledover the last 10 years, and only a minority of patients are nowtreated within the time limits prescribed by CARO (Canadian Associationof Radiation Oncologists)," William J. Mackillop, MD, whoheaded the study, said in an interview with Oncology News International.

The study was based on information from the province's oncologydatabase, which contains diagnostic, therapeutic, and follow-updata for all Ontario cancer patients since 1982, said Dr. Mackillop,professor of oncology, Radiation Oncology Research Unit, Queen'sUniversity, Kingston, Ontario. Cancer sites studied included thelarynx, cervix, lung (non-small-cell), prostate, and breast. Datafrom 12,002 patients were reviewed.

This information enabled the investigators to determine the followingthree time-delays for patients: time from diagnosis to makingthe radiation oncology referral (t1); time from making the radiationoncology referral to the first radiation oncology consult (t2);and time from the first radiation oncology consult to initiationof treatment (t3).

Dr. Mackillop and his colleagues were then able to determine ifthe total delay was outside the control of the radiation oncologyservice (t1), was due to availability of radiation oncologists(t2), or was more sensitive to availability of technical facilitiesand personnel (t3).

Delays Exceed CARO Guidelines

The Ontario study showed that delays increased significantly overthe 10-year study period for all sites reviewed (see table). "Mostof the deterioration in access to radiotherapy over the last 10years has been due to an increase in the interval between consultationand initiation of treatment," he said. "This reflectsa shortfall of technical facilities and/or technical personnel."For example, the total median delay time during the study increasedby 179% for larynx cancer, 106% for cervix cancer, and 63% forprostate cancer. In all cases, these increases were primarilydue to longer delays from radiation oncology consultation to theinitiation of radiotherapy (Int J Radiat Oncol Biol Phys 30:221-228,1994).

The CARO guidelines recommend a 2-week or less interval from referralto first radiation oncology consult (t2) and a 2-week or lessinterval from first consult to initiation of radiotherapy (t3).

For larynx cancer, 80% of 1982 patients met the CARO guidelinefor time from consult to initiation of treatment. By 1991, only10% met this standard. For cervix and lung cancer, more than 80%of 1982 patients began radiotherapy within 2 weeks of consultation.By 1991, only 40% met the 2-week criteria.

Furthermore, these data may underestimate the magnitude of theproblem, since only patients who succeeded in getting treatmentwere studied while no estimate was available for patients whowere not referred because of waiting lists. Also, data were notrecorded at one participating Ontario center from 1989 to 1991because of resource limitations.

These treatment delays may create psychological distress for patientsas they wait for cancer treatment, Luther W. Brady, MD, professorof radiation oncology, Hahnemann University, Philadelphia, toldOncology News International in an interview. In his editorialin response to the Canadian study, Dr. Brady noted that long delaysmay also lead to deleterious effects on treatment outcomes.

Treatment of most patients in the United States conforms to theCARO standards, Dr. Brady said, but with increasing pressure onfacilities for high quality care, he warned US radiation oncologiststhat they must not allow waiting lists and delays to develop.

The Ontario group will soon report a study analyzing the impactof delayed treatment on patient outcome. In addition to the influenceof delays on quality of life, delays that exceed the doublingtime of common malignancies may affect the rate of local controland possibly even the rate of metastases, although these riskshave not been quantified, the researchers said.

The available evidence shows that the longer delays are due tothe aging Canadian population. More cancer cases occur in theelderly, but there has not been a sufficient increase in radiotherapyresources to keep up with these demographic changes, Dr. Mackillopnoted.

Failure to Act

This situation was anticipated in a 1973 comprehensive externalreview by consultants for the Ontario Ministry of Health thatrecommended increasing radiotherapy resources. A subsequent reviewin 1985 identified failure to act on the 1973 study as the causeof delay problems at that time. This 1985 review by consultantswarned of a deteriorating situation if no changes occurred. Bothstudies, it turns out, proved correct.

The challenge now facing Canadian radiation oncologists is howto best mitigate the effects of the shortage of radiotherapy resources,the Ontario investigators say. Eliminating inefficiencies willbe required, and hard choices about which services to maintainand which to discontinue may be involved.