Our 'Paper of the Month' for April is timely as it looks at the impact of prolonging time to surgery on survival rates.

Christof Kaltenmeier, Chengli Shen, David S. Medich, David A. Geller, David L. Bartlett, Allan Tsung, and Samer Tohme. Time to surgery and colon cancer survival in the United States. Annals of Surgery 2019 Dec 10 [Epub ahead of print]

What is known on the subject?

In the times of Corona virus pandemics, quarantine conditions and delaying or cancelling the elective surgery, timing to cancer surgery becomes very important.

In this paper authors investigated whether it is safe to delay the surgery for colon cancer and whether prolonged timing has an impact on survival. Still there are limited national data evaluating the association between time to surgery (TTS) and the effect on overall survival (OS).

What this study adds

The authors used the data from National Cancer Data Base (NCDB) which comprises Cancer-accredited hospitals in the United States and Puerto Rico to analyze a nationwide cohort of colon cancer patients between 1998 and 2012, aged 18 years or older, diagnosed with non-metastatic colon cancer having surgical treatment as their first modality 6 months after their diagnosis date. Time intervals between diagnosis and surgery were set at 30-day increments, with the exception of the last 2 intervals combined due to smaller numbers and the first interval limited to the first week after diagnosis. Intervals to assess overall survival (OS) were thus categorized as <7, 7 to 30, 31 to 60, 61 to 90, 91 to 120, and 121 to 180 days.

The study included a large cohort of 514,103 patients. Authors found that black race, greater distance from hospital, women, higher Charlson comorbidity scores, and care at an academic centre increased steadily in the unadjusted data with an increase in the delay interval to surgery.

After analysis was adjusted for these factors, there was significant decrease in overall survival when TTS was outside 7 to 30 days. There was a significant increase in mortality when surgery was performed 31 to 60 days after diagnosis (HR 1.13, P < 0.001, 95% CI 1.02– 1.25), 61 to 90 days after diagnosis (HR 1.49, P < 0.001, 95% CI 1.19–1.85), within 7 days after diagnosis (HR 1.56, P < 0.001, 95% CI 1.45–1.68), 91 to 120 days after diagnosis (HR 2.28, P < 0.001, 95% CI 1.61–3.23), and 121 to 180 days after diagnosis (HR 2.46, P < 0.001, 95% CI 1.48–4.09) compared to 7 to 30 days after diagnosis.

In addition, to addressing its central hypothesis, this paper also provided important insights in to the real world data on timing to surgery and its effect on survival.

Implications for colorectal practice

This analysis of >513,000 patients establishes a consistent relationship between prolonged TTS as an independent predictor of worse mortality that is most consistent beyond 30 days. Efforts to minimize that interval are appropriate. Consideration should be given to establishing reasonable and attainable goals for the timing of surgery to provide this population with a clinically relevant survival benefit.

Report by Audrius Dulskas