Wait Times for Prostate Cancer Care in Newfoundland and Labrador

Taylor Ferrier B.Sc, Chris French MD, Maria Mathews PhD. Memorial University of Newfoundland

Objectives
First, we used frequencies to describe the characteristics of the sample. Second, chisquare tests were used to detect differences between the six wait time benchmarks (outcomes), covariates, and three independent variables: (a) community of residence, (b) urgency, and (c) age of men with suspected of confirmed prostate cancer. For each outcome, significant variables from the chi-square analyses were included in a multiple logistic regression. The final model was used to identify any significant predictors in whether or not men met or did not meet each individual benchmark. Statistical analysis was performed using SPSS 18.0.

Introduction
Using a retrospective chart review, we examined the charts of all men who had a biopsy for suspected prostate cancer between April 1, 2009-March 31, 2010 at the Health Science Centre in St. Johns, NL. Eligible men were NL residents and who had their first prostate biopsy within the study period. Patients whose charts were not available or if we could not determine eligibility, who were younger than 19 years of age, died, or had a previous cancer diagnoses were excluded. Since there were no established Canadian benchmarks for these tested wait intervals, we asked a local urologist to identify acceptable wait times for each interval.

Results
There were 341 men eligible for this study. We found in Table 1 men experienced the longest median wait of 68 days (0-310) between general practitioner (GP) referral to first visit with the urologist, 28 days (0-151) from the decision to biopsy to date of biopsy, 40 days (13-404) from the biopsy date to notification of the results, and 30 days (0-272) from decision to treat to first treatment. Throughout each interval, men meeting the locally established benchmarks ranged from 13.4 to 50.7%. Seven percent of men met the Canadian Society for Surgical Oncologys (CSSO) benchmark for referral to first consultation and 33.1% of men met the CSSOs benchmark for conclusion of preoperative tests to first treatment. Table 2 suggests older age (70 years) was a significant predictor for three of the six outcomes. After controlling for other significant predictors, compared to younger men (<70 years), older men were 5.82, 3.12 and 3.53 times more likely to have met the locally established benchmarks between decision to treat to first treatment, GP referral to notification of results, and GP referral to first treatment, respectively. Table 3 shows that radical prostatectomy and radiotherapy made up 75.2% of the treatment modalities.

Table 1: Proportion of Men Meeting Local & National Benchmarks

Benchmark Reference 1.NL Expert Opinion, 2010 2.CSSO, 2010 NL Expert Opinion, 2010 NL Expert Opinion, 2010 1.NL Expert Opinion, 2010 2.CSSO, 2010 NL Expert Opinion, 2010 NL Expert Opinion, 2010 Benchmark Definition GP Referral to first visit with urologist Decision to biopsy to date of biopsy Date of biopsy to notification of results Decision to treat to first treatment GP Referral to notification of results GP Referral to first treatment Benchmark 1. 60 days 2. 14 days 14 days 40 days 1. 14 days 2. 14 days 102 days 116 days Met Benchmark n (%) 1.145 (42.5) 2. 24 (7.0) 114 (33.4) 173 (50.7) 1.52 (33.1) 2.52 (33.1) 56 (16.4) 21 (13.4) Did Not Meet Benchmark n (%) 1.196 (57.5) 2.317 (93.0) 227 (66.6) 168 (49.3) 1.105 (66.9) 2.105 (66.9) 285 (83.6) 136 (86.6) Median (days) 68.0 28.0 40.0 30.0 154.0 188.0 90th Percentile (days) 146.6 69.0 140.4 91.4 292.2 289.6

Table 2: Predictors of Men Who Met the Local Benchmarks

Benchmark Definition GP Referral to first visit with urologist Variable Odds Ratio 1.00 0.60 1.00 2.02 1.00 2.82 1.00 5.82 1.00 0.20 0.52 1.00 3.12 1.00 3.53 95% Confidence Interval p-value 0.025 0.39 0.94 0.003 1.27 3.22 <0.001 1.81 4.39 <0.001 2.43 13.95 0.003 0.08 0.50 0.19 1.46 0.001 0.217 0.002 Community of residence Urban (10 000) Rural (<10 000) Community of residence Decision to biopsy to date of Urban (10 000) biopsy Rural (<10 000) Prostate cancer Date of biopsy to notification of No Cancer results Has Cancer Age Young (<70 years) Old ( 70 years) Decision to treat to first treatment Gleason Low ( 6) Medium (7) High (>7) GP Referral to notification of Age results Young (<70 years) Old ( 70 years) Age Young (<70 years) GP Referral to first treatment Old ( 70 years)

Table 3: Distribution of Treatment Modalities

Treatment Modality Radical prostatectomy Radiotherapy Watchful waiting (including active surveillance) Other (brachytherapy*, palliative care, hormone therapy) n (%) 76 (48.4) 42 (26.8) 28 (17.8) 11 (7.0)

Brachytherapy is not offered to men with prostate cancer in NL. Men in our study choosing brachytherapy received their treatment in Ontario.

Conclusions
Men seeking care for suspected or confirmed prostate cancer in NL experience lengthy delays throughout the care pathway. Few men met both locally and nationally established benchmarks. Study results will be used to identify strategies to improve the timeliness of specialist care in the province. They will also provide the groundwork for ongoing monitoring and interprovincial comparisons.

1.54 6.31 0.003 1.52 8.19

Acknowledgements
Taylor Ferrier holds a Masters Fellowship Award from NLCAHR. This study was support by a Canadian Institute for Health Research (CIHR) grant to study wait times held by Dr. Maria Mathews.

Three independent variables were tested in each regression. Only significant predictors are illustrated. Urgency variable was defined differently based on available information to the urologist at each interval.