Britain fares rather badly in international comparisons of cancer patients' survival rates. Relative survival rates in England and Wales1 are generally lower than in Europe,2 which in turn are lower than rates in the United States.3 The differences between England and Wales and the rest of Western Europe in survival rates for colon cancer and female breast cancer arise primarily in the first six months after diagnosis, suggesting that these differences may relate to later presentation or delays in treatment for British patients.
Given this background, the government has pledged to “end waiting times for cancer surgery, thereby helping thousands of women waiting for breast cancer treatment.” The assumption is that reduced waiting times will lead to more rapid diagnosis, earlier instigation of care, and reduced psychological morbidity. Indeed, the NHS has been asked to set a target of two weeks from referral by a general practitioner to first hospital outpatient appointment for all suspected cases of cancer.
In order to investigate the delays that British cancer patients face, we undertook a retrospective survey of patients with newly diagnosed cancer in October 1997.
Subjects, methods, and results
We invited all English acute hospital trusts (whether cancer centres or units) to submit relevant information on all new patients with a cancer diagnosis confirmed during October 1997. The data were collected during April and May 1998, allowing a tracking period of up to six months after diagnosis. We measured how long the patients were required to wait from their initial referral by their general practitioner for an outpatient appointment, for their first definitive treatment (when appropriate), and for any subsequent treatment.
Data returns were made by 218 (98%) of the 223 trusts, representing 13 454 patients. A greater proportion of patients who had been urgently referred by their general practitioner were seen within two weeks compared with those who were non-urgent referrals. However, the results clearly showed that there was substantial variation in patients' waiting times according to tumour type, whether the initial referral was coded urgent, and the region where treatment was undertaken. The table shows that waiting times for urgent appointments were significantly less than the waiting times for non-urgent appointments: this was so for all 10 types of cancer and for time from general practitioner referral to first definitive treatment as well as for time from referral to outpatient appointment.
Discussion
The underlying causes of the variation in waiting times observed here are not explained by the audit data, and we do not suggest that there are “across the board” implications for clinical outcome in the waiting times reported. Clearly, these are clinical issues and would vary with specific types of cancer. However, the focus on reducing unnecessary delays in cancer treatment stems from the belief that the earlier disease is detected, the more quickly multidisciplinary care can be instigated and the better the outcome. Irrespective of the specific waiting times reported here, the key contribution of this study is in establishing baseline data which can be used to set targets for improvement and, crucially, to monitor such attempts.
Table.
Waiting times for cancer patients in England, from general practitioner referral to first outpatient appointment and to first definitive treatment (excluding referrals not by general practitioner)
| Type of cancer and urgency of referral | Time to first outpatient appointment (days)
|
Time to first definitive treatment (days)
|
|||
|---|---|---|---|---|---|
| Median (interquartile range) | When 90% of patients seen | Median (interquartile range) | When 90% of patients seen | ||
| Breast (n=1517): | |||||
| Urgent | 9 (4-15) | 22 | 27 (15-41) | 62 | |
| Non-urgent | 14 (8-21) | 29 | 35 (21-57) | 90 | |
| Colorectal (n=1023): | |||||
| Urgent | 13 (6-21) | 35 | 39 (21-64) | 95 | |
| Non-urgent | 27 (16-43) | 60 | 72 (44-104) | 147 | |
| Lung (n=767): | |||||
| Urgent | 7 (3-13) | 21 | 39 (21-61) | 91 | |
| Non-urgent | 12 (7-22) | 33 | 47 (28-77) | 112 | |
| Ovary (n=189): | |||||
| Urgent | 6 (1-14) | 23 | 21 (14-40) | 64 | |
| Non-urgent | 24 (7-32) | 39 | 45 (18-77) | 116 | |
| Cervix (n=321): | |||||
| Urgent | 22 (10-34) | 58 | 46 (28-79) | 123 | |
| Non-urgent | 41 (27-65) | 93 | 75 (44-119) | 181 | |
| Uterus (n=223): | |||||
| Urgent | 19 (9-29) | 39 | 47 (24-83) | 114 | |
| Non-urgent | 29 (19-41) | 55 | 73 (50-122) | 163 | |
| Prostate (n=677): | |||||
| Urgent | 19 (9-29) | 44 | 53 (26-91) | 143 | |
| Non-urgent | 41 (23-56) | 77 | 111 (64-183) | 292 | |
| Bladder (n=627): | |||||
| Urgent | 20 (7-32) | 48 | 57 (28-84) | 124 | |
| Non-urgent | 33 (21-57) | 70 | 82 (56-119) | 178 | |
| Stomach (n=241): | |||||
| Urgent | 10 (4-22) | 36 | 42 (21-73) | 112 | |
| Non-urgent | 27 (18-50) | 70 | 75 (36-100) | 150 | |
| Oesophagus (n=249): | |||||
| Urgent | 11 (5-21) | 33 | 44 (24-63) | 85 | |
| Non-urgent | 24 (13-35) | 57 | 65 (37-112) | 154 | |
Acknowledgments
We thank Dr Stephen Green for his advice on the development of the guidance notes used by the trusts in completing the survey instrument and the many trust staff who gave their time in the collection of the data.
This paper was first posted on www.bmj.com on 13 March 2000
Footnotes
Funding: The study was funded by the Department of Health (HSC1998/999)
Competing interests: None declared.
References
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