The “New Normal” of Cancer Treatment Delays Is Nothing New | Health Disparities | JAMA Network Open | JAMA Network
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Invited Commentary
December 14, 2020

The “New Normal” of Cancer Treatment Delays Is Nothing New

Author Affiliations
  • 1Division of Hematology and Oncology, Vanderbilt University School of Medicine, Nashville, Tennessee
  • 2Division of Hematology/Oncology, University of Maryland Medical Center, Baltimore, Maryland
  • 3Department of Geriatrics and Palliative Medicine and Division of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, New York City, New York
JAMA Netw Open. 2020;3(12):e2030507. doi:10.1001/jamanetworkopen.2020.30507

In their article “Assessment of Time-to-Treatment Initiation and Survival in a Cohort of Patients with Common Cancers,” Cone et al1 bring to the forefront an important and topical issue about the risks of delays in cancer care. They focus on delays in time-to-treatment initiation (TTI) with curative-intent therapy following diagnosis in a retrospective cohort study leveraging the National Cancer Database for nonmetastatic prostate, breast, and colon, and stages I and II lung cancer treated from 2004 to 2015. They find evidence that longer TTI is associated with higher mortality across cancer types, most significantly in colon cancer and early-stage lung cancer.

As the authors note, this study’s major limitation is the inability to identify the reason for the treatment delay. For example, close to 90% of included patients with colon cancer received treatment in the reference 8- to-60-day time period from diagnosis. This could suggest that patients experiencing delays in TTI are outliers who are fundamentally different than the underlying cohort and thus not representative. Along with the non–small cell lung cancer subgroup, the colon cancer subgroup also had much higher Charlson Comorbidity index scores compared with the breast and prostate cancer subgroups. And despite incomes being similar across cancers, patients with lung and colon cancer had lower rates of private insurance, and an outlying 58% of patients with colon cancer had Medicaid insurance. Yet, importantly, the authors also find harms in delay in intermediate-risk and high-risk prostate cancer, despite expert guidance that early treatment is less important and despite lower rates of early treatment across risk stages. This finding mitigates concerns that patients with longer TTI may be outliers physiologically or otherwise. TTI is likely influenced by both medical and social factors that also influence overall survival. Still, while the reason for delay for individual patients in the cohort is unknown, the findings of this study are consistent across the data set, biologically plausible, and worthy of concern.

This study also draws attention to the importance of prioritizing timely cancer care, even during the coronavirus disease 2019 (COVID-19) pandemic. In addition to being the most common cancers, breast, colon, prostate, and lung cancer are the cancers most commonly detected via population-wide screening. Although US Preventive Services Task Force guidelines vary across types of cancer and are least prescriptive for prostate cancer, the fundamental purpose of screening is to identify asymptomatic cancers in a timely fashion where earlier diagnosis and treatment are known to improve survival. Decades of research in these diseases have shown that earlier diagnosis is beneficial. A body of research in disparities demonstrates that delays in cancer diagnoses and treatment disproportionally affect racial and ethnic minority populations and the poor, who also experience worse overall and cancer-specific mortality.2

Primary care, the most important conduit for cancer screening and initial evaluation of new symptoms, has been the hardest hit economically and the most subject to profound disruption and restructuring during the current COVID-19 pandemic.3 Research by Alexander et al4 showed an overall decrease of 21.4% in primary care utilization during 2020, with greater decreases in office-based visits, new medication starts, and monitoring of clinical markers like blood pressure and cholesterol. The pandemic may have long-term implications for access to timely care, particularly given existing geographic, racial, and economic disparities in primary care access, as well as the inadequate funding and lower reimbursements that limit new graduates’ interest in pursuing the field.

Whether for pandemic or financial reasons, patients themselves must frequently weigh the costs and benefits of seeking medical care. They are fundamentally ill equipped to make this decision. In the classic Rand health insurance experiment,5 families assigned to varying levels of cost-sharing reduced medical care proportional to cost, regardless of whether it was medically effective or less effective care, and with greatest adverse effects on poor and sick patients. Patients are not irrational; rather, lay people are not physicians adequately trained to distinguish between essential and inessential medical care. We see this discordance in clinical practice: a patient is concerned about bothersome symptoms; a physician is concerned about potentially life-threatening risks. Cancer screening, which seeks to identify malignant neoplasms that are presymptomatic, is understandably a low priority for many patients. Furthermore, even after a screening test shows abnormalities or a biopsy confirms a diagnosis of cancer, the financial toxicity of cancer care informs many patients’ decisions. Cancer diagnoses provoke fear and anxiety, but cancer is also one of the most expensive conditions to have and to treat, and patients frequently delay or limit care because of high costs. In a University of North Carolina cancer cohort study,6 26% of patients reported they “have to pay for more medical care than [they] can afford,” which was associated with nonadherence to needed care, particularly prescription medications and mental health services; patients reporting financial toxicity also described increased rates of delayed care.

The global COVID-19 pandemic has brought ethical questions of allocation of medical resources to the forefront. We face triage decisions about ventilator allotment and vaccine rollouts. Confronting a deadly pandemic, we navigate trade-offs between the dangers of social isolation, economic hardship, and the virus itself. In many centers, cancer care delivery has been disrupted and nonstandard therapies offered in an effort to minimize exposure of this high-risk group to the virus. Yet, sadly, we have long forced individuals to make similar compromises on their own. For many people in the US, health care is an expensive, scarce resource that is difficult to access.

Disparities in access to care and resulting delays in treatment reflect inequities and inadequacies in the health care system.2 Adequate investment in primary care could improve outcomes, given the cost-saving and mortality benefits of preventive care, early diagnosis and timely treatment, and holistic, comprehensive management provided by a good primary care team. For example, greater primary care physician supply is associated with reduced overall and cancer-specific mortality.7 Finally, improvement in insurance coverage for cancer and other chronic conditions could alleviate the financial toxicity and accompanying trade-offs patients are forced to make between their health and their livelihood.

The article by Cone et al1 does not answer the nuanced clinical question of the precise impact of delaying definitive therapy, or of delaying timely access to cancer treatment across the care continuum in each different type of cancer, stage, and patient. Given that prospective evaluation is not likely feasible or ethical, this article supports avoiding unnecessary treatment delays. The implications in appropriately balancing the urgency of cancer care and the threat of COVID-19 exposure in the pandemic are more complex. More generally, on a societal level, this article underscores the fundamental ethical importance of equitable, accessible, affordable, and timely cancer care. Worse outcomes caused by lack of access to care, while often out of view, are society’s responsibility. How much we tolerate inadequate care depends on how much value we place on peoples’ lives.

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Article Information

Published: December 14, 2020. doi:10.1001/jamanetworkopen.2020.30507

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Baum LVM et al. JAMA Network Open.

Corresponding Author: Laura Van Metre Baum, MD, Division of Hematology and Oncology, Vanderbilt University Medical Center, 2220 Pierce Ave, Nashville, TN 37232-630 (

Conflict of Interest Disclosures: Dr Smith reported receiving honoraria from Teva Pharmaceutical outside the submitted work. No other disclosures reported.

Cone  EB, Marchese  M, Paciotti  M,  et al.  Assessment of time-to-treatment initiation and survival in a cohort of patients with common cancers.   JAMA Netw Open. 2020;3(12):e2030072. doi:10.1001/jamanetworkopen.2020.30072Google Scholar
Zavala  VA, Bracci  PM, Carethers  JM,  et al. Cancer health disparities in racial/ethnic minorities in the United States. Br J Cancer. 2020. doi:10.1038/s41416-020-01038-6PubMed
Phillips  RL, Bazemore  A, Baum  A. The COVID-19 tsunami: the tide goes out before it comes in.  Health Affairs Blog. April 17, 2020. doi:10.1377/hblog20200415.293535
Alexander  GC, Tajanlangit  M, Heyward  J, Mansour  O, Qato  DM, Stafford  RS.  Use and content of primary care office-based vs telemedicine care visits during the COVID-19 pandemic in the US.   JAMA Netw Open. 2020;3(10):e2021476. doi:10.1001/jamanetworkopen.2020.21476PubMedGoogle Scholar
Lohr  KN, Brook  RH, Kamberg  CJ,  et al.  Use of medical care in the Rand Health Insurance Experiment. Diagnosis- and service-specific analyses in a randomized controlled trial.   Med Care. 1986;24(9)(suppl):S1-S87.PubMedGoogle Scholar
Knight  TG, Deal  AM, Dusetzina  SB,  et al.  Financial toxicity in adults with cancer: adverse outcomes and noncompliance.   J Oncol Pract. 2018;14(11):e665-e673. doi:10.1200/JOP.18.00120PubMedGoogle ScholarCrossref
Basu  S, Berkowitz  SA, Phillips  RL, Bitton  A, Landon  BE, Phillips  RS.  Association of primary care physician supply with population mortality in the United States, 2005-2015.   JAMA Intern Med. 2019;179(4):506-514. doi:10.1001/jamainternmed.2018.7624PubMedGoogle ScholarCrossref
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