Avoidable or unavoidable delay

Pancreatic cancers have the poorest overall survival of any major cancer. Part of the reason for this dismal outlook is the lack of symptoms until the tumour is quite advanced. Consequently, initial presentation to the doctor is delayed or late. However, after the initial contact with a doctor, other factors can also lead to delays in diagnosis and subsequent treatment.   

At the recent 2009 Gastrointestinal Cancers Symposium (GICS) held in San Francisco, researchers from Virginia Mason Medical Centre presented the findings of their study on the magnitude of delay in diagnosis and treatment of patients with pancreatic cancer. They reviewed their tumour registry from 2004 and 2005 and identified 134 pancreatic cancer patients – 40 had resectable pancreatic cancer, 40 had locally advanced disease and 48 had metastatic disease (2009 GICS Abstract 137, presented 16/01/2009). They found that the median time from first patient symptom to first provider (ie the doctor) contact was 30 days (range 1 – 1460 days). The median time from first provider contact to date of tissue diagnosis was 35 days (range 1 – 365 days) and time from diagnosis to treatment was 21 days (range 0 – 120 days). The median delay was nearly 4 months (112 days) and 25 of 134 patients (19%) experienced a delay of 6 months or longer.

The typical median survival for patients with resectable pancreatic cancer is 16 – 22 months. For locally advanced disease, it is 9 – 14 months. The best treatment option for patients with pancreatic cancer is surgical removal. However, due to the late presentation, potentially curative surgery is feasible only in a small proportion of patients. Therefore, prolonged delays from the time of presentation to definitive treatment will likely affect patients’ outcome adversely. Anything that could shorten the wait / delay during this period is likely to help, especially with those who have operable / resectable disease.

The one area where the wait / delay can be shortened is the time from first provider contact to date of tissue diagnosis. There are 2 schools of thought on this aspect of the management process for patients with resectable disease. One group of doctors will insist on a tissue diagnosis before proceeding to surgery while the other group of doctors will operate based on clinical and radiological evidence. The former is more conventional in USA and the later is more the British approach.

Either approach is acceptable and widely practiced worldwide. Achieving a tissue diagnosis prior to surgery means there is no chance of operating on a non-malignant problem. However, there is a small chance that, despite biopsy, one is still unable to establish a tissue diagnosis. In such circumstance, the surgeon will still have to consider performing the operation ‘blind’ to the diagnosis. For those who operate based on clinical and radiological evidence, there is always a small chance that a major operation is performed on someone without a malignant condition, thus, subjecting an individual to the risks of an operation. In reality, the risk of performing an unnecessary operation if you have good clinical and radiological evidence is small.

In an ideal environment, we should be able to get a tissue diagnosis within 2 days of contact with the first provider. Subsequently, definitive treatment would be delivered within a week. Unfortunately such is not the case in real life. Even at the famous Memorial Sloane Kettering in New York, a few months ago a patient of mine was told the wait for a liver biopsy appointment for suspected liver metastases was 3 – 4 weeks. Establishing tissue diagnosis prior to surgery can be very important in some circumstances. In this situation, the patient will have to contend with the unavoidable delay. In situations where tissue diagnosis prior to surgery is unlikely to alter the management approach, the step for tissue diagnosis may be omitted and the doctor moves directly to definitive surgery. This will save the patient from an avoidable delay.

The patient should be given the facts and allowed to choose. If the patient wants a definitive diagnosis before surgery then there will be a delay. Ultimately, it is the patient’s choice.