Interventions addressing primary care attachment and upstream social determinants may improve early detection and access to curative therapy in lung cancer stage at diagnosis and surgical treatment persist in Ontario.
Abstract
Lung cancer is the leading cause of cancer mortality in Canada, with most cases diagnosed at advanced stage. Despite universal healthcare, social determinants of health may impact stage at diagnosis and access to treatment. We examined the association between these factors, stage at diagnosis, and receipt of surgery in Ontario. We conducted a population-based retrospective cohort study of adults diagnosed with lung cancer in Ontario from 2007–2023 using linked administrative health data. Stage was obtained from the Ontario Cancer Registry. Factors included income, primary care attachment, immigration status, geographic region, and distance to the nearest cancer centre. Logistic regression identified factors associated with stage IV diagnosis. Among 106,867 patients with available stage data, 52.6% were diagnosed with stage IV disease; 19.1% were stage I. Patients without a family physician were significantly more likely to present with stage IV cancer compared with those fully rostered (62.1% vs 51.5%; adjusted OR 1.55, p < 0.001). Females had lower likelihood of stage IV diagnosis than males (OR 0.85, p < 0.001). Increasing household income was associated with reduced likelihood of stage IV disease (OR 0.92 for highest vs lowest quintile, p < 0.001). Immigrants were less likely to be diagnosed with stage IV cancer than non-immigrants (OR 0.77, p = 0.001). Frailty was associated with higher odds of stage IV disease (OR 1.01, p = 0.009). Surgical resection was performed in 56.1% of patients with stage I disease and 1.4% with stage IV disease. Receipt of surgery decreased with advancing age (27.0% < 50 years vs 7.3% ≥ 80 years), higher comorbidity burden (25.4% with 0 vs 5.0% with ≥5 comorbidities), and lack of primary care attachment. Marked social inequities in lung cancer stage at diagnosis and surgical treatment persist in Ontario. Interventions addressing primary care attachment and upstream social determinants may improve early detection and access to curative therapy.
IMPORTANCE
Evidence regarding the association of the diagnosis to treatment interval (DTI) and survival can inform clinical care and health policy. Data in this regard are currently lacking for cervical cancer.
OBJECTIVE
To examine the relationship between the DTI and overall survival (OS) in a contemporary cohort of cervical cancer patients receiving curative surgery.
METHODS
We conducted a retrospective cohort study using population-based data of incident cases of cervical cancer diagnosed January 2008-September 2023 followed to December 1st, 2023 in Ontario, Canada. Eligible patients were > 18 years of age with stage I-III disease who received curative surgery. Multivariable Cox Proportional Hazards regression analyses were performed to evaluate the association between the DTI and OS adjusting for important confounders. The DTI was modeled categorically and using restricted cubic splines to visualize non-linear relationships.
RESULTS
1501 incident cases of cervical cancer receiving curative surgery were included. The majority of patients were diagnosed with stage I disease (n = 1185, 79%). The median DTI was 80 (60-107) days. After multivariable adjustment, the hazard ratio (HR) estimates were elevated for the shortest and longest DTIs: >2-6 weeks HR: 2.33 (95%CI 1.14-4.77); >22-26 weeks HR: 1.76 (95%CI 0.59-5.27); in comparison to the middle referent interval >10-14 weeks. The restricted cubic splines exhibited a U-shaped pattern of risk, with higher effect estimates among the lowest and highest DTI values.
CONCLUSION
In this population-based study we did not find that prolonged DTIs to be significantly associated with poorer survival. Cautious interpretation of the results is needed given the potential impact of the waiting time paradox.
M. Jalink, W. King, Christopher M. Booth et al.· Cancer Epidemiology· 0 citations
Socioeconomic position (SEP) influences cancer care and outcomes, even in countries with government-funded healthcare. This population-based study examined associations between SEP, rectal cancer care and survival of patients in the Netherlands. Data from 25,995 patients with Stage I-III rectal cancer diagnosed between 2015 and 2023 were obtained from the Netherlands Cancer Registry. SEP was categorised as lower, intermediate or higher using income-based postal code data. Associations between SEP and detection method, treatments, and outcomes were analysed using multivariable logistic regression. Relative survival and relative excess risk (RER) of death were calculated using a generalised linear model. Compared to lower SEP, higher SEP patients were younger (median age 66 vs. 71 years), more often male (65% vs. 59%), had better performance status (71% vs. 52% PS0), fewer comorbidities (63% vs. 50% CCI 0) and lower obesity rates (15% vs. 23%). Higher rates of Stage I tumours (34% vs. 30%), screen-detection (45% vs. 38%), laparoscopic surgery use (93% vs. 90%), and lower rates of colostomies (64% vs. 71%) and adverse in-hospital outcomes (44% vs. 55%) were observed among higher SEP patients (all p < 0.001). Five-year relative survival improved with increasing SEP (79.5% lower, 82.4% intermediate, 84.9% higher SEP; p < 0.001), with lower excess mortality for higher SEP patients (RER 0.90, 95% CI 0.81-0.99). SEP-related differences were observed in screening, stage at diagnosis, surgical treatment and survival. Although several disparities were partly explained by comorbidity and BMI, others persisted, highlighting the need for targeted strategies to reduce differences between SEP groups in rectal cancer management and outcomes.
Suzanne E. N. de Vries, Felice N. van Erning, Mieke J. Aarts et al.· International Journal of Can...· 0 citations
PURPOSE
We evaluated LCS eligibility rate under USPSTF criteria among patients diagnosed with primary lung cancer and examined LCS utilization prior to lung cancer diagnosis.
METHODS
Patients aged 50-80 years with a lung cancer diagnosis in 2018-2024 who received care at a tertiary health system in Southern California were included. LCS eligibility was determined using available structured smoking history in the electronic medical record (EMR). The primary outcome was LCS eligibility using 2021 USPSTF guidelines. Secondary outcomes included LDCT completion among LCS-eligible patients during the two years preceding their diagnosis based on USPSTF guideline in effect at diagnosis time, the completeness of EMR structured smoking history, and the associations between sociodemographic characteristics and these outcomes.
RESULTS
1,867 patients were included (mean age 67±8 years, 51.6% (962/1866) male, 53.4% (955/1790) White, 2.4% (43/1790) Black, 31.5% (564/1790) Asian). Further, 11.6% (208/1786) were Hispanic. At diagnosis, 46.3% (786/1697) were never smokers, 44.5% (756/1697) former smokers, and 9.1% (155/1697) current smokers. LCS eligibility was determined for 1,119 patients, of whom 13.2% (148/1119) met eligibility criteria according to the 2021 USPSTF guidelines. Multivariable analysis showed women (OR 0.32; 95% CI, 0.21-0.47; P<0.001), Asian race (OR 0.35; 95% CI, 0.20-0.62; P<0.001), other or mixed race (OR 0.48; 95% CI, 0.24-0.97; P=0.04), and Hispanic ethnicity (OR 0.38; 95% CI, 0.17-0.82; P=0.01) were less likely to be LCS-eligible. Among the 137 eligible patients, only 13 (9.5%) had received LDCT.
CONCLUSION
Our findings emphasize two critical barriers to effective LCS: the limited reach of existing eligibility criteria and inadequate uptake of LDCT.
M. Sharifian, Alvin Tran, Omar Cespedes-Gomez et al.· Journal of the American Coll...· 0 citations
Background: Lung cancer is one of the most diagnosed cancers and the leading cause of cancer-related deaths in Ontario. For patients with medically inoperable stage I non-small cell lung cancer (NSCLC), stereotactic body radiation therapy (SBRT) is recommended. However, there is limited evidence on how the diagnosis to treatment interval (DTI) impacts survival, which is relevant to inform health policy and improve patient outcomes.
Objective: To investigate the association between DTI and survival for patients with stage I non-adenocarcinoma NSCLC treated with SBRT in Ontario.
Methods: We conducted a population-based retrospective cohort study using linked ICES health administrative datasets, applying recently published international consensus-based methodology recommendations for investigating the association between cancer DTI and overall survival (OS). The cohort included Ontario patients with stage I NSCLC diagnosed between January 1, 2010, and June 30, 2019, treated with curative SBRT. Patients with adenocarcinomas were excluded because of histological diversity uncontrollable within the available data. A 5 month from diagnosis landmark time was used to limit immortal time bias and the wait time paradox. Kaplan Meier analysis was used to visualize survival. Multivariable Cox proportional hazards models were used to assess the association between DTI and OS and cancer-specific survival (CSS), adjusting for relevant factors.
Results: The cohort included 532 patients with a median DTI of 61 (interquartile range: 46-79) days. Kaplan Meier analysis suggested longer DTIs were associated with worse OS. In adjusted Cox models, each 1-week (aHR=1.04 (95% CI=1.01–1.08)), and 4-week (aHR=1.19 (95% CI=1.03–1.38)) increase in DTI was associated with worse OS. Similarly, each 1-week (aHR=1.05 (95% CI=1.01–1.10)), and 4-week (aHR=1.22 (95% CI=1.03–1.45)) increase in DTI was associated with worse CSS. Findings remained robust in sensitivity analyses.
Conclusions: Our findings suggest that efforts to shorten DTI may improve patient survival in this population.
Cassidy Laub, Paul Nguyen, M. Jalink et al.· McMaster University Medical...· 0 citations
Introduction Cervical cancer remains a major public health concern in India, with a substantial burden of late-stage diagnosis and limited survival data from tertiary care settings. Disease-free survival (DFS) is a key indicator of treatment effectiveness and recurrence risk, yet evidence on its determinants in Indian populations remains limited. This study aimed to assess DFS pattern and identify prognostic factors among cervical cancer patients treated at a tertiary care center in India. Data and methods A retrospective–prospective cohort study was conducted at Sir Sunderlal Hospital, Banaras Hindu University, Varanasi. The study included 587 cervical cancer patients diagnosed between 2011 and 2021, with follow-up until February 2025. Disease-free survival was defined as the time from first follow-up after treatment completion to recurrence. Kaplan–Meier methods, log-rank tests, and Cox proportional hazards models with time-varying covariates were used to estimate survival and identify predictors. Results The median follow-up duration was 23.4 months (IQR: 10.2–52.6). Most patients were aged ≤50 years (51.8%), from rural areas (68.5%), and presented with advanced disease (FIGO stage II: 36.3%; stage III: 45.8%). Squamous cell carcinoma accounted for 91.8% of cases, and 76.0% had tumor size ≥4 cm. Kaplan–Meier analysis showed a sharp decline in DFS during early follow-up, indicating a higher risk of recurrence in the initial years. Significant differences in DFS were observed by age (p=0.002), tumor size (p=0.005), vaginal involvement (p=0.011), lymph node involvement (p=0.012), and addiction status (p=0.023). In multivariable analysis, age ≤50 years (AHR = 1.64; 95% CI: 1.16–2.34), tumor size ≥4 cm (AHR = 2.98; 95% CI: 1.44–6.15), and vaginal involvement (AHR = 1.56; 95% CI: 1.06–2.29) were independently associated with poorer DFS. Tumor size also showed a significant time-varying effect (HR = 0.97, p=0.010). Conclusion DFS in cervical cancer is strongly influenced by tumor burden and locoregional spread. The early decline in survival highlights the need for intensive follow-up during the first two years post-treatment. Targeted interventions focusing on early detection and risk-stratified management are essential to improve outcomes in resource-limited settings.
Bajarang Bahadur, S. Choudhary, Deshna Oswal et al.· Frontiers in Oncology· 0 citations