QUESTION: My mom has been diagnosed with colon cancer and has an appointment to see a surgeon. We are so anxious about this whole process. What is the average waiting period from the consultation visit to surgery?
ANSWER: It’s certainly understandable that you feel anxious about your mother’s diagnosis. Most people want to have a cancer removed as fast as possible.
Provincial health authorities have established general targets for how long patients should wait for surgery. (I will return to those targets later.)
But it’s still hard to say how long your mother will have to wait because the timing of her surgery will likely depend on the characteristics of her tumour.
Indeed, we are moving into an era of “personalized” medicine that’s been made possible, in part, by recent advances in deciphering the genetic differences of tumours.
Many patients now receive treatments that are designed to attack specific aspects of their tumours. They may also get numerous therapies – from chemo to radiation.
“What we have learned is that people do best if we can attack the cancer with a variety of different methods, and the key is what sequence they should go in,” says Dr. Calvin Law, Chief of the Odette Cancer Centre at Sunnybrook Health Sciences Centre.
Patients usually undergo a series of tests to help their doctors to understand the characteristics of the tumour and to chart a customized treatment strategy.
In some cases, chemotherapy – a cancer-fighting medication – is given prior to the surgery.
“Chemo can shrink a tumour a lot – and the smaller the tumour, the easier it will be to do the surgery,” says Dr. Law.
However, receiving the chemo first moves the operation further down the road. “You usually need a one-to-two-month break between the last chemo treatment to the time of your surgery,” says Dr. Law.
“Chemotherapy can stay in your body well beyond four weeks. So, your doctor has to time your surgery for when most of the chemo has faded away,” he explains. Otherwise, the residual chemo can hinder healing of the surgical incision.
Some patients also get additional chemotherapy following surgery. And, once again, there is a waiting period before the next stage of therapy can begin. The surgery must be completely healed – which can take four-to-eight weeks – before chemo can be re-started.
With this background in mind, let’s now return to the targets recommended by provincial health authorities.
Cancer Care Ontario (CCO), an agency of the Ontario Ministry of Health and Long-Term Care, has established two key targets.
The first is the time until the initial appointment with a cancer surgeon, following the referral from a family doctor or another medical specialist.
This target is 21 days, although some cancer centres (including Sunnybrook) try to schedule most patients within two weeks of receiving the referral.
The second target is for the date of the surgery. This is the wait time from when the patient is “ready” for surgery until that patient actually goes into the operating room, says Dr. Robin McLeod, vice-president of Clinical Programs and Quality Initiatives at CCO.
In other words, “ready” means the patient has completed all preliminary treatments, such as chemotherapy, and the medication is no longer in the body. The clock starts ticking at that point.
Of course, some patients need surgery more urgently than others. For that reason, CCO has four priority categories, each with a different target:
- Priority 1: The patient’s life is in imminent danger and surgery should be performed right away. A tumour may have grown to the point where it is causing an obstruction – such as a blockage in the bowel or windpipe. About 1 per cent of patients fall into this category.
- Priority 2: The tumour is getting close to causing a life-threatening obstruction or another complication, but it hasn’t happened yet. These patients should be operated on within two weeks. This group makes up about 5 to 10 per cent of patients.
- Priority 3: This represents the bulk of cancer patients – 60 to 70 per cent. They should have surgery within 28 days.
- Priority 4: The patients in this category have relatively slow-growing tumours – such as prostate or thyroid cancers. The target is 84 days.
Members of an expert panel came up with these targets in 2004, based on the best available evidence and their clinical experience. Some of the other provinces – including British Columbia, Saskatchewan and Nova Scotia – have adopted the same targets.
For most patients, those who fall into Priority 3, “we are fairly confident that it [the cancer] isn’t going to spread in 28 days” as they wait for their surgeries, says Dr. McLeod.
The targets, she adds, represents “the maximum time we think patients should wait.”
Cancer doctors readily acknowledge that any wait can be psychologically distressing.
All told, the extra medical appointments, diagnostic tests, and therapies prolong the treatment – and that drawn-out process can contribute to a patient’s anxiety.
“We do understand our patients’ frustration, but we are hoping to create the most advanced treatment plan,” says Dr. Law. After all, the additional tests and treatments boost the odds that the tumour will be successfully beaten back.