The wait times for definitive surgery in patients with nonmetastatic solid tumors are up to 50% longer on average than they were just a decade ago, according to a cohort study drawn from the National Cancer Database (NCDB).

On the basis of a retrospective analysis of the NCDB, the largest oncologic registry in the US, the growth in wait times has been particularly marked at high-volume and academic centers, according to a report published on July 12 in JAMA Surgery.

The growth in surgical wait time is complex and might be due at least in part to more sophisticated characterization of tumors, but the trend is still worrisome, according to the senior author, Timothy R. Donahue, MD, chief of the Division of Surgical Oncology at David Geffen School of Medicine at University of California, Los Angeles.

“The goal should not simply be to make surgery happen faster. Some of the delay before surgery is important. Multidisciplinary review, appropriate staging, medical optimization, and thoughtful treatment planning can all improve care,” Donahue said.

“We need prospective studies to better understand which delays are necessary and beneficial and which are inefficiencies that we can safely eliminate.”

There are multiple studies in nonmetastatic potentially curable cancer, many of which are cited in the new study, that link inferior survival to longer surgical wait times. As a result, the authors’ interpretation of the growing delays over the past decade is that system-level strategies to reduce time to definitive surgery are “urgently needed.”

When average wait times in the most recent era studied, those in 2022-2023 were compared with those in 2012-2015, the climb was about 50% for colon cancer (31 vs 20 days), 43% for pancreatic cancer (32 vs 23 days), 40% for gastric cancer (49 vs 35 days), 32% for breast cancer (45 vs 31 days), 29% for lung cancer (52 vs 41 days), and 26% for esophageal cancer (48 vs 38 days), the study found.

Moreover, the wait times in general climbed incrementally for each of the four successive study periods (2012-2015, 2016-2019, 2020-2021, and 2022-23). The trend was highly significant over the study period for breast, colon, lung, pancreas, and gastric cancers (P < .001 for all). This trend was also significant for esophageal cancer but with a lower statistical significance (P < .05).

High-Volume Centers Have Longer Wait Times

When change over time in surgical wait times at community hospitals, integrated network programs, and academic or high-volume centers were compared, there was some variability, but academic or high-volume centers overall had the longest delays to surgery, particularly when compared with the other setting in the most recent era. Pancreatic cancer, for which wait times were relatively stable, was the single exception.

Excess demand relative to capacity is suspected of being a contributor to surgical delay at high-volume centers, Donahue said. This demand is likely due to evidence that better outcomes are achieved in these settings but there are potential risks for centralization of cancer care, according to a study published in Journal of Clinical Oncology. Relatedly, Medscape Medical News previously reported that several studies have suggested that local physician practices can deliver comparable outcomes to larger institutions for certain patients with advanced cancer, although not necessarily for ones requiring surgery.

Indeed, Donahue questioned whether the delay imposed by noncomplex procedures in high-volume centers is becoming counterproductive to national efforts to improve survival. As a potential solution, both Donahue and the authors of an accompanying JAMA Surgery editorial suggested moving certain cases out of these centers.

“Not every cancer operation needs to be performed at a tertiary or quaternary center,” Donahue said. Although “there is a well-established relationship between surgeon and hospital volume and outcomes in complex cancers,” an effort to distribute less complex cancer operations across centers “may improve access and timeliness while still providing high-quality care.”

The authors of the editorial emphasized the potential to reduce bottlenecks at high-volume centers by funneling fewer noncomplex cases to community hospitals or other regional settings. For example, they reported that there is an unclear advantage for performing definitive resections in noncomplex breast and colon malignancies in high-volume centers.

The greater efficiency of triaging cancer surgeries by complexity was supported by the trend for lower surgical delays in the setting of Commission of Cancer-accredited Integrated Network Programs, which are multi-facility systems that can coordinate cancer care across multiple facilities. In this NCDB analysis, the shortest wait times for lung, pancreatic, and esophageal cancer in the most recent era were in these settings.

Does Comprehensive Workup Benefit All Patients?

In an interview with Medscape Medical News, Sherry M. Wren, MD, senior author of the editorial, questioned whether all patients benefit from the increasingly sophisticated risk stratifications now performed routinely in many centers. Wren, who is also a professor of surgery at Stanford Medicine in Palo Alto, California, suggested that a speedy excision in a noncomplex, localized tumor might often be a key variable for a good outcome.

“Not every case needs to be evaluated by a tumor board,” she said.

Wren also noted that she thinks there are a lot of obstacles unrelated to patient workup and evaluation that contribute meaningfully to surgical wait times, including insurance pre-authorizations.

“This is an important study because it draws attention to a potential problem, but these data really do not provide much information about how the problem can be solved,” Wren said.

There were many more variables implicated associated with longer surgical wait times that were not clearly related to patient intake and processing. For examples, Black patients, low income patients, Medicaid patients, and patients who travel long distances for care, were all found to have greater surgical wait times on average than those without these characteristics.

Important Questions Remain Unanswered

Another detail missing from this study, which was brought up by Noah Cohen, MD, is whether longer surgical wait times in any specific patient subset led to worse outcomes.

Given that there is an implication that growing wait times for definitive surgical outcomes might be threatening survival relative to a faster time to surgery, he called the failure to provide supportive data “surprising,” in an interview with Medscape Medical News.

“In an era where treatment for certain cancers may vary widely based on biomarker testing, taking the extra time to ensure that the most appropriate treatment is recommended may result in better outcomes. This study does not address this, and it cannot be addressed using the NCDB dataset,” said Cohen, who is section chief for complex GI Surgical Oncology in the Division of Hepatobiliary and Pancreatic Surgery at New York University Langone School of Medicine in New York City.

Donahue acknowledged this criticism in an interview, but he maintained that the potential problem is significant and said awareness is “an important first step,” and that he thinks surgical wait times are a variable worth monitoring.

“Some of the problems may be relatively straightforward to address, including delays in obtaining medical records, in conducting sequential rather than coordinated testing, or in navigating patients through increasingly complex systems,” he said.

Given the tension between surgical wait times and the need to pursue an adequate workup, Donahue agreed that solutions might not be easy.

“The larger challenge is making timeliness a priority while preserving the things that have made cancer care better. We do not want to sacrifice multidisciplinary care, appropriate regionalization, or thoughtful treatment planning just to make the number of days smaller,” he said. Moving forward, “the goal is to identify the delays that add value and eliminate the ones that do not.”

Donahue reported having financial relationships with Renovo and Trethera. Wren and Cohen reported having no potential conflicts of interest.

Ted Bosworth, a career medical writer based in New York City, has been covering advances in clinical medicine, including dermatology, for several decades.