Division of General Surgery, Department of Surgery, University of California Los Angeles Santa Monica, California, United States
Disclosure(s):
Haley Tupper, MD, MS, MPH: No financial relationships to disclose
Purpose: Delayed surgical treatment of early-stage NSCLC is associated with increased recurrence and mortality (1,2). Several assessments must be accomplished in a timely manner pre-operatively (Figure 1). We sought to characterize the association between 1) Each pre-operative step and delayed resection and 2) Patient characteristics and completion time for each step. Methods: This retrospective cohort study evaluated stage I and II NSCLC patients ages 18-85 who underwent primary resection between 1/2009 and 12/2019 in a multi-center, integrated hospital system. Patient sociodemographic and clinical characteristics, as well as pre-operative assessment and surgery dates, were abstracted from electronic health records and the institutional cancer registry. Diagnosis date was defined by most recent pre-operative chest computed tomography. Time-to-surgery from diagnosis was stratified into “delayed” (>4 weeks) and “timely” ( < 4 weeks) resection based on research showing time-to-surgery greater than 4 weeks in early-stage NSCLC is associated with increased recurrence (2). Tests of independence were used to characterize the association between 1) the median time to accomplish each pre-operative step and delayed surgery and 2) the median time to accomplish each pre-operative step and individual patient characteristics, specifically age, sex, race/ethnicity, primary language, neighborhood deprivation index (NDI), smoking status, Charlson comorbidity score (CCI) and clinical stage. Results: 2789 patients were analyzed; 274 (9.8%) received timely surgical resection, while surgical resection was delayed in 2515 patients (90.2%). Delayed surgery was associated with significant bottlenecks at each pre-operative step (Figure 1). The median time from diagnosis to PET CT was 6 days (IQR: 0-10) in patients receiving timely resection, compared to 19 days in delayed surgical cases (IQR: 10-31) (p < 0.001). The median time from diagnosis to placement of thoracic surgery consult request was 6 days (IQR: 2-8) versus 24 days (IQR: 13-38) (p < 0.001) and the median time from diagnosis to completion of pulmonary function tests (PFTs) was 11 days (IQR: 6-15) versus 28 days (IQR: 16-44) (p < 0.001) for timely and delayed surgeries, respectively. There was no association between pre-operative step completion time and differences in sex, race/ethnicity, primary language and smoking status. However, patients who were younger (ages 18-54), had higher clinical stages (stage IIA or IIB), fewer co-morbidities (CCI 0-2) or were from the least deprived neighborhoods (4th NDI quartile) experienced the fewest delays in completing one or more of the pre-operative assessment steps (see Table 1). Conclusion: Many necessary pre-operative assessment steps must be completed before surgical resection. Delays at each step are associated with overall delayed surgical resection. PFT completion is a particularly prominent bottleneck. Surgical fitness concerns and competing priorities in older and multi-morbid patients may also delay pre-operative assessment completion. Although there were no clear inequalities with regards to gender, primary language (English) and race/ethnicity, patients from resource-rich neighborhoods (NDI) were able to complete PET scans and obtain thoracic surgery consults more quickly. These delays, particularly those that are non-clinical in nature, warrant further evaluation to ensure equal, unbiased access to appropriate care.
Identify the source of the funding for this research project: Kaiser Permanente Division of Research Delivery Science Grant
