Best Practices

Timeliness of Lung Cancer Diagnosis and Treatment

Most patients received timely histopathologic confirmation of diagnosis, but surgery candidates faced significant delays in care in this quality improvement analysis.

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Lung cancer is the leading cause of cancer-related deaths worldwide and causes more deaths than do colorectal, breast, and prostate cancers combined.1 An estimated 155,870 Americans are expected to die of lung cancer in 2017, and these deaths account for about 26% of all cancer deaths.1 The overall 5-year survival rate for patients with lung cancer is 16.8%.2 However, this rate varies considerably, from 54% for those with early-stage cancer to 26.5% for those with locally advanced cancer and 4% for those with distant metastases.2

The Institute of Medicine’s Committee on Quality Health Care in America recognized timeliness of care as 1 of 6 important dimensions of health care quality.3 Delays in timely diagnosis and treatment of cancer, especially lung cancer, can result in significant emotional distress, impaired quality of life, increased use of health care resources, and, arguably, increased cost of care.4 In addition, delayed diagnosis of cancer can lead to negligence litigation.4

In the U.S., there are no federal standardized guidelines regarding timeliness of lung cancer care. In 2000, the RAND Corporation, a research organization, published several quality indicators recommending lung cancer diagnoses be established within 2 months after initial abnormal chest radiographs and treatment be offered within 6 weeks after diagnosis.5

Using these recommendations as benchmarks, a quality improvement study was conducted to determine the time lines of comprehensive lung cancer care at the Dayton VAMC in Ohio. The primary aim of the study was to evaluate adherence to the RAND criteria (the only U.S.- based guidelines) for the diagnosis and treatment of lung cancer in Dayton VAMC patients. The secondary aim was to assess the effect of preoperative cardiopulmonary rehabilitation on timeliness of treatment. The authors plan to use the results of the study to guide and improve cancer practices at the Dayton VAMC.


The authors conducted a retrospective study of a series of 121 consecutive patients who had lung cancer that was confirmed at the Dayton VAMC with a cytohistologic diagnosis between January 2011 and December 2013. The study was approved by the Dayton VAMC Research and Development committee and the Wright State University Institutional Review Board. After data collection and review, all patient identifiers were replaced with sequential numbering.

The Dayton VAMC is a 356-bed facility serving 16 counties and > 50,000 patients. Lung cancer diagnosis and management are collaboratively undertaken by various Dayton VAMC departments, including pulmonology, radiology, interventional radiology, pathology, thoracic surgery, medical oncology, radiation oncology, and palliative care. The facility, fully equipped with scanners for positron emission tomography and magnetic resonance imaging, provides comprehensive cancer care without the need for referrals to outside facilities for any part of care from diagnosis to end of life.

The study patients were identified from the Dayton VAMC tumor registry. Patients with only biopsy-confirmed malignancy were included in the study. Patients who did not follow up before biopsy or did not pursue treatment after biopsy confirmation were excluded from analysis where appropriate.

Patient data collected included age, sex, presenting symptom, histology, cancer stage, treatment modality, cardiopulmonary rehabilitation, and if applicable,
tumor size. Patients were retrospectively followed for 3 years. Charts reviewed did not include outcomes information. Historically, delays have been categorized as provider delays, patient delays, or system delays. Provider delay stems from the primary care provider’s (PCP) failure to investigate a presenting symptom further, patient delay from the patient’s failure to seek medical care or to follow through on medical advice in a timely manner, and system delay from the health care organization’s failure to obtain imaging or biopsy results in a timely manner. Assessment of system delay is focused on quality improvement at a treatment center.

In the present study, the primary aim was to assess system delay. The authors analyzed delay during 3 different periods: time to diagnosis (interval from date an abnormality was found on chest radiograph or computed tomography scan to date of tissue diagnosis); time to treatment initiation (interval from date of histopathologic diagnosis to date of treatment initiation); and time from date of initial abnormal imaging to date of treatment initiation. With RAND criteria applied, time to diagnosis longer than 60 days was considered diagnostic delay, time to treatment longer than 42 days was considered treatment delay, and the sum of these periods (102 days) was considered total delay.5 Patients with diagnosis and treatment intervals that fell within these criteria were considered in adherence with the RAND criteria.

Means and standard deviations were reported for continuous variables and counts and percentages for categoric variables. Calculations were performed with IBM SPSS 21.0 (Armonk, NY).

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