This study quantifies the time between important diagnostic time points for patients with lung and GI cancers treated with radiation therapy as well as compares symptom scores between the two tumour groups over the course of their radiation consultations and therapy encounters. We found that patients with lung cancer experienced longer wait times before having a biopsy and receiving a diagnosis compared to patients with GI cancer. This longer time frame is consistent with prior reports and may in part be due to many symptoms of lung cancer present similar to non-malignant conditions such as chest infection[8, 9]. The differences can also be partly explained by the nature of investigative testing for GI patients, such as endoscopies, where the first investigative test and biopsy are completed at the same time point. Our results support our hypothesis that patients with lung cancer would experience a greater delay in their diagnosis compared to GI patients, specifically to receive a confirmed diagnosis.
The median number of days from the first investigation to the initial RO consult was shorter for patients with lung cancer compared to GI by one week. To better understand these differences, we divided both tumour groups into two sub- groups: those presenting with a new diagnosis and those with recurrent/metastatic/progression of cancer. The results revealed that newly diagnosed patients with lung cancer had the longest time frame between their first investigation and RO consultation compared to other sub-groups. There was a difference of 25 median days between newly diagnosed patients with lung and GI cancers. This further supports the finding that individuals who are newly diagnosed with lung cancer may face a diagnostic delay in confirming their diagnosis.
Once patients with lung cancer were in the cancer system, the time interval between their referral and initial consultation with a radiation oncologist was generally the same as the GI group, two weeks on average. National groups are working to determine wait time benchmarks for medical services, including radiation therapy. The Wait Times Alliance of Canada currently recommends a (non-tumour specific) maximum of 10 working days between referral and appointment with the radiation oncologist . It is also recommended 10 working days between radiation consultation and first radiation treatment sessions . Our results indicate just over half of lung (51.6%) and GI (53.3%) patients meet the benchmark timeline between their referral and RO consultation. A higher proportion of patients with lung cancer (56%) meet the recommended benchmark for time between RO consultation and radiation treatment start, compared to GI (44%), and thus the differences in experiences between the two tumour groups are unlikely explained by this timeline.
Our results indicate a greater proportion of patients with lung cancer reported high symptom scores during treatment compared to GI. These results support the second part of our hypothesis that a higher proportion of patients with lung cancer would report more severe symptom scores. Approximately 17% and 15% more lung patients reported high symptom scores at their first and last treatment review appointments, respectively, compared to GI. Further, our results are novel as we observed three different time points to compare symptom scores. We found between the consultation and first treatment review, 25% of lung patients experienced worsening symptoms compared to only 4% of GI. In our cohort, patients with GI cancer more commonly reported moderate-severe scores on symptoms including pain, nausea and lack of appetite. For these types of symptoms, many GI patients will receive referrals to dieticians and receive medications to assist in early symptom management at their consultation. Although we see some increases in moderate-high scoring of certain symptoms from consultations to first treatment review, patients with GI cancer reported trends in improved well-being between these time points as well.
Our results indicate a need for improved support to patients with lung cancer, which may help improve their radiation treatment experience. Our study found a higher proportion of patients with lung cancer reported moderate-high symptom scores for depression, anxiety and overall well-being at each time point, as well as shortness of breath (except for last treatment review). The proportion of patients with lung cancer reporting moderate-high well-being scores (moderate-high scores reflecting worse well-being) consistently increased over time. Anxiety, depression and overall wellbeing can be complex symptoms to intervene on, and guidelines exist for managing symptoms of anxiety and depression in cancer patients [20, 21]. However, many patients are known to decline psychological or social support even when offered, adding another level of complexity to symptom management [22–24]. As well, preventing or managing dyspnea can be challenging, especially in older patients with additional comorbidities such as COPD or heart disease. In our study, patients with lung cancer were older in age compared to GI. Although we did not have comorbidity index data of our study population, the literature supports that lung patients typically have multiple comorbidities with worse health status [25, 26]. Although there may be challenges with symptom interventions, patients with lung cancer may benefit from increased support which may help improve their experience.
Few studies have compared the experience of patients with lung cancer and patient experience with other tumour sites. Ayanian et al. compared overall ratings of the quality of cancer care for patients with lung and colorectal cancer . Excellent ratings were reported in 44% of lung and 53% of patients with colorectal cancer. Similar to our study population, stage IV cancer was more common in lung (41%) than patients with colorectal cancer (19%) . Worse ratings for quality of care were reported for those with worse health status. Halpern et al. noted patients with lung cancer reported lower general health status and less favorable patient experience scores compared to patients with breast and colorectal cancer , although specific reasons for differences in experience were not investigated in either study.
This study has several limitations. This study only compared lung to one other tumour group. Including different or additional comparison groups may have highlighted other important factors. Additionally, because this was real-world data and not part of a clinical trial, we acknowledge the extent of missing data regarding symptom complexity scores, especially comparing treatment time points including last review. Non-response during this time may reflect sicker patients who are not captured and we may be underestimating the symptom burden towards the end of treatment. Another limitation is that this study was conducted retrospectively for the same time period as our previous patient experience study within the radiation department, which collected experience data from patients anonymously, and we do not have experience measures for these same patients. Therefore, we were unable to construct models using experience measures as outcomes, limiting our ability to draw a definite connection between these observations and our experience observations. Our conclusions are therefore inferential. Given these limitations, the data collected for our time points and basic demographic information was complete and accurate as dates do not change and are not open to interpretation. Further, the symptom data we collected was documented by patients in real-time at their appointment, therefore accurately reflecting their symptoms experienced. A strength of this study includes having these data, including dates and real-time collection, incorporated into one dataset.