Waiting Times

Waiting times can refer to:

  • The time it takes for a patient who is referred to the service to be seen by the clinician
  • The time it takes for a patient to start treatment after they have been seen by the clinician
  • The combination of both these times

Lengthy waiting times have become more common for a multitude of reasons:

  • Increased utilisation of radiation therapy in common cancers (adjuvant breast after lumpectomy/mastectomy, radical prostate therapy)
  • Increased complexity of treatment with the move away from field based to 3D conformal and now IMRT treatment
  • Increasing patient population
  • Increasing incidence of malignancy
  • Shortage of professional staff
    • Shortage of medical physicists (particular problem in Australia)
    • Shortage of other specialists (oncologists and radiation therapists)
  • Inefficient procedures or practices
    • An example would be the ongoing use of paper files

Local issues may exist in some departments:

  • Regional and rural centres have difficulty in attracting permanent staff (oncologists, physicists and therapists) for a number of reasons:
    • Less availability of modern technologies
    • Lifestyle - there are limited cultural and educational opportunities in most regional centres compared to the capital cities
    • Partners - in many couples, both members have careers of their own. This can make it difficult to relocate unless both people are: a) able to find new work in the regional centre; and b) be willing to leave some aspects of their lifestyle in the cities
    • Expense - regional centres may be more expensive to live in due to higher costs of basic goods (eg. petrol, food) although this may be countered by significantly lower property prices
  • Isolated centres are less able to divert patients to nearby departments when they have an influx of new patients

Normal Waiting Times

It is not possible to start all treatment immediately after a patient is seen in clinic. There are several reasons for this:

  • Rushing plans can potentially lead to human errors or cutting corners. It is better to spend a reasonable amount of time in planning to achieve the best result for the patient, unless the condition is grave enough (cord compression, haemorrhage) to warrant urgent planning.
  • Patients may need further staging or interventions (e.g. tooth extraction prior to head and neck treatment)

Therefore it is reasonable to have 'acceptable' waiting times to start treatment. These are often based on the time of surgery for adjuvant treatments.

  • Urgent cases need to start as soon as possible, and include spinal cord compression, haemorrhage, or other life threatening conditions such as SVCO with respiratory compromise after stunting
  • Semi-urgent cases should start within 1-2 weeks. These include palliative cases for pain relief or whole brain radiotherapy, as well as curative cases where there is a risk of disease progression or significant symptoms (or if the referral was delayed!)
  • Category A cases should start within 4 weeks. These include adjuvant treatments as well as most radical cases
  • Category B cases should start within 2 months. This includes prostate cancer and non-urgent treatment (eg. for keloid, hyper salivation etc)

Effects of Waiting Times

Direct Effects

Delayed treatment time has been shown to negatively impact on survival for radical treatment, due to increased number of clonagens and potential for distant spread during the waiting period. Patients who have delayed treatment may need higher doses and therefore have higher toxicity rates. Unfortunately, aside from the psychological distress caused by delayed treatment, the effect of delayed treatment on tumour outcome is a stochastic effect much like radiation carcinogenesis. It is not possible to determine whether a poor outcome after treatment is attributable to treatment delay in a single patient; rather it is likely to be seen on a population basis only. Randomised studies comparing delayed treatment to timely treatment are unethical and therefore most studies examining effects of treatment delay are retrospective and subject to bias and confounders. It is estimated that a 1 month delay in treatment reduces likelihood of local control by 5-10%.
Delayed treatment also impacts on palliative patients, who have increased length of suffering due to delay in starting treatment.

Indirect Effects

If radiotherapy treatment is delayed, it will have flow on effects for other patients who require treatment:

  • Patients may be offered alternative treatments which may be less effective or give rise to more complications (e.g. oropharyngeal tumours, mastectomy instead of breast conserving therapy)
  • Patients may have radiotherapy omitted with poorer outcomes
  • Patients may be referred to other centres which could be inconvenient
  • Patient care in the institution may be worse due to cutting of corners, lower morale, and decreased time to see patients on treatment due to other commitments.

Staff morale is often impacted upon by long waiting times due to frustration and longer hours at work, and this can also impact on quality of care.

Economic Effects

Radiotherapy effectiveness will be compromised by delays in treatment on a state or nation-wide basis. This will potentially lead to decreased funding for radiation oncology which may cause a vicious circle. Additionally, there may be increased costs for patient care due to delays in treatment (e.g. a patient may require a tracheostomy because treatment does not start quickly enough, requiring intensive care, months of rehabilitation)

Societal Effects

Poorer outcomes for patients can lead to negative coverage of radiation oncology. This can lead to poor staff morale, loss of funding and reduced public confidence in the treatment. Radiation oncologists are medicolegally liable for poor results that arise as a result of delayed treatment, even if it is governmental policy that leads to the problem in the first place.

Management of Waiting Lists

Prolonged waiting times need immediate, short term, medium term and long term approaches.

Immediate Management

Urgent cases require staff to stay back late to treat patients.
If there is an acute problem that can not be rectified by increasing staff hours, then patients should be referred to another centre with an acceptable waiting time. The radiation oncologist should be proactive in arranging patient handover to other centres.

Short Term Management (Days - Weeks)

An increase in treatment hours should be discussed with therapists, nurses and oncologists. This can involve starting treatment early or running machines after hours (eg. extending treatment time from 5 pm to 6 pm). This often encounters hurdles (e.g. union regulations) and does not fix the underlying problem. This approach also costs more money due to overtime costs or hiring of locum staff.
Methods to treat patients with alternatives to radiotherapy should be explored. For example, induction chemotherapy may be suitable for some head and neck cases.

Medium Term Management (Months to Years)

Focusing on the reasons behind the delay in treatment is essential:

  • Are there enough machines to treat the number of patients?
  • Are there enough staff to see the referred patients?
  • Are there enough therapists to perform the required planning?
  • Are there enough therapists to run the machines?
  • Is there sufficient medical physics support?
  • Are there inefficient processes? Can these be improved (e.g. electronic medical records system)
  • Is the team working effectively? Can this be improved (e.g. staff

If the problem can be identified then hiring more staff or installing more machines may be the answer. A new radiotherapy centre may be the answer if the problem is arising from increasing population.

Long Term Management (Years - Decades)

This includes:

  • Long term strategic planning (identifying population growth areas and planning radiotherapy centres to fit the needs of the population)
  • Identification of radiotherapy as a required component in cancer treatment (eg. the Tripartite committee report)
  • Cancer prevention (smoking cessation, screening programs)