When Treatment Delay May Be Beneficial in Patients: Further Investigation Needed

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Basil Morson, an eminent pathologist from St. Mark’s hospital in London, who died in 2016, described the polyp-cancer sequence in the large bowel in 1974.1 He hypothesized that colorectal cancer originated from neoplastic transformation of the mucosa through a spectrum of progressive invasion into, and beyond, the bowel wall. In this progressive process, metastatic disease resulted from malignant cells invading lymphatic and vascular channels, more likely to occur in advanced disease. It still seems likely that this sequence is responsible for ≥80% of colorectal cancers and is the fundamental basis underlying colorectal cancer screening. Removal of colonic polyps is preventative, and complete luminal excision of a polyp cancer may cure many patients with an early colorectal cancer. The exact time sequence of the polyp-cancer sequence is unknown, but circumstantial evidence suggests months to, perhaps, many years as the time frame from a polyp to an invasive cancer. If correct, moderate delays in treatment, of the order of 4 to 6 weeks from diagnosis to surgery, are unlikely to have a major detrimental effect on patient outcome.
However, it is now accepted that not all colorectal cancers originate from a polyp or follow this orderly sequence of progressive invasion. When it comes to cancer diagnosis and management, intuitively the shortest time to surgery should be associated with better outcomes, and substantial delays in diagnosis, or to treatment, would be detrimental to overall and disease-free survival. In this context, it is rather sobering that, when seeking information on delays in colon cancer on the internet, some of the most accessible sites, at the top of the page, are medical litigation firms encouraging patients to sue clinicians for delay in diagnosis and presumably, by extrapolation, delays to surgical intervention.
Without doubt, a diagnosis of colorectal cancer can be devastating for a patient and their family and is accompanied by a range of complex reactions and emotions around prognosis, the possible need for a stoma, and both quantity and quality of life. Individual patient reactions are variable and not always predictable. A diagnosis of colorectal cancer for most people generally encompasses a feeling that surgery should be immediate to prevent tumor dissemination and death. Any delays can often engender anger and bitterness, and a poor outcome may even be attributed to a short delay. As doctors and health care workers, it is easy to underestimate that, generally, for the patient with a new diagnosis of cancer, their whole world has come to an impasse, time stands still, day becomes night, and limitations to delivery of surgical treatment, such as a finite normal working-day operating list, weekends, or public holidays are meaningless in the knowledge that a potentially lethal, uninvited guest has invaded their whole being and threatens their existence. Many fear that minutes matter and that action should be immediate. In some, the reaction may be the opposite, with a feeling that time is needed to adjust to this news and to accept a life-changing, life-altering, and potentially lethal intervention, whether it be surgery, chemotherapy, radiotherapy, or a combination.
For both scenarios, the article by Wanis et al2 goes some way to reassure patients, relatives, and carers that moderate delays in treatment for colon cancer do not influence overall or cancer-specific survival in patients with pathological stage I to III colon cancer. They have used an arbitrary figure of 30 days from decision to operate to surgical resection as a cutoff for an appropriate time interval.
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