Is faster enough? Wait time intervals in prostate cancer treatment

Diagnostic assessment units (DAUs) of various types and various names are becoming increasingly common in our resource restricted healthcare system. We generally perceive them to be beneficial to the patient and their family, the healthcare provider and the system. We give them different names, such as Rapid Access Clinics, Rapid Diagnostic Units, Cancer Assessment Clinics, to be more descriptive or unique. They are conceived and constructed with the most noble of intentions. When we are asking for money to build these units, we quote such benefits as shorter wait times, improved access, single portal access, multidisciplinary consultation, collaborative research and improved quality of care. However, when you search the literature for evidence of these improvements, it is somewhat elusive. Sethukavalan and colleagues in their paper on wait times in this issue of CUAJ are to be commended for attempting to address at least one of these potential benefits.¹ In a systematic fashion, they tried to measure a number of wait time intervals for prostate cancer patients who ultimately were treated with radiation therapy. They concluded that when patients were referred through their rapid diagnostic unit, their wait times were significantly reduced when compared to a community-based and less standardized process. However, this is a small study that relies in part on patient recall of seminal dates; also due to its retrospective nature, other potential confounding variables could not be measured. In spite of this, they make a good case for reduction in wait times, and I think we the readers are inclined to buy in. After all, don’t we all believe DAUs are better?

As Director of a prostate cancer DAU (in Ottawa we call ours a CAC, or Cancer Assessment Centre) for the past 6 years, I have to count myself among the believers. Similarly, we have seen tremendous improvements in wait times for assessment and transrectal ultrasound (TRUS) biopsy. The existing literature has shown this in a number of studies, but that seems to be where we all stop measuring and evaluating what we are doing within the DAU. We know that reducing wait times for most prostate cancer patients has no impact on cancer outcomes. As our own DAU has matured, we have come to realize that measuring prostate cancer wait time benefits may be only scratching the surface and is perhaps the least important function.

Our DAU has become the physical and virtual hub for prostate cancer care for our region. It serves as the core of our Community of Practice, which is a regional multi-hospital initiative wherein stakeholders (doctors, nurses, hospital administrators etc.) prospectively gather and present performance data, share best practices, strive for standardization and establish regional care pathways, among many other quality improvement projects. Our goal is to be able to measure and improve care in our region and not just within our assessment unit. The DAU provides a place where we can measure functional outcomes with standardized metrics pre-and post-treatment. Practice changes, such as revisions to TRUS biopsy antibiotic protocols, are rolled out first in our DAU and then throughout the region. We can audit and share continence and sexual function results following treatment, for example. Improvements in these domains are probably going to provide more “bang for the buck” for our patients than simply getting in sooner.

In these times of decreasing PSA-driven referrals and reduced rates of treatment, we are starting to use the existing DAU infrastructure to provide improved access and multidisciplinary care for other tumour types, such as bladder, testis and kidney cancers. In fact, there are likely many more benefits in these more lethal diseases in which shorter wait times alone could save lives.

The next major challenge to all DAU’s is to begin to systematically evaluate more than wait times. These units can be much more than one-stop-shopping rapid access clinics.