August 31, 2026
7 min read
Key takeaways:
- Wait times from diagnosis to initial treatment increased between 2012 and 2023 for all six cancer types analyzed.
- The proportion of patients who waited at least 60 days also increased for all cancer types.
Patients who need cancer surgery are waiting longer for initial therapy, according to results of a retrospective cohort study.
The time between diagnosis and start of first-course treatment increased significantly between 2012 and 2023, findings showed.
Data derived from Sakowitz S, et al. JAMA Surg. 2026;doi:10.1001/jamasurg.2026.3212.
The trends — observed for all six cancer types analyzed — appeared particularly pronounced for individuals treated at high-volume hospitals, as well as those referred for care.
Timothy R. Donahue
“The findings are alarming. The numbers are higher than we expected, and the fact they were consistent across all cancer types we looked at was particularly surprising,” senior author Timothy R. Donahue, MD, told Healio.
Comprehensive assessment
Prior research that assessed the relationship between treatment delays and oncologic outcomes yielded conflicting results, according to study background.
Still, guidance from several entities — including National Comprehensive Cancer Network and the Institute of Medicine — suggest timely access is a vital component of quality cancer care.
Delivery of cancer treatment has evolved considerably over the past couple decades, with high-volume hospitals now providing a larger proportion of complex surgical care.
Previous studies demonstrated advantages of receiving treatment at high-volume centers, including greater adoption of advanced multimodality therapies, fewer complications and longer survival. However, whether health system consolidation and the centralization of care has led to unintended consequences — such as capacity constraints or increased travel burdens for patients — that could cause delays between diagnosis and treatment had not been established.
Donahue and colleagues aimed to perform the first comprehensive assessment of contemporary waiting times in cancer surgery care pathways in the United States.
“As a cancer surgeon, I clearly see the benefits of consolidation and greater integration of health systems. However, I also see the potential inefficiencies and areas where there might be room for improvement,” Donahue, chief of the division of surgical oncology at UCLA’s David Geffen School of Medicine at the time of the study and currently chair of surgery at Weill Cornell Medicine and surgeon in chief at NewYork-Presbyterian/Weill Cornell Medical Center, said in an interview. “We hypothesized that wait times might increase as health systems have consolidated and cancer care has become more complex and multidisciplinary.”
The researchers used the National Cancer Database to examine trends in waiting times from diagnosis of nonmetastatic cancer to first-course treatment among patients undergoing definitive cancer surgery.
The analysis included 2.7 million adults (mean age, 63.5 years; 85% women) diagnosed with one of six stage I to stage III malignancies — breast, colon, esophageal, gastric, lung or pancreatic cancers — between 2012 and 2023 who underwent curative-intent surgical resection at American College of Surgeons Commission on Cancer-accredited hospitals.
Time from diagnosis to first-course treatment — defined as upfront surgery or neoadjuvant therapy — served as the primary outcome.
Consistent increases
The percentage of patients with standard wait times — defined as less than 30 days — declined from 44% for those diagnosed in 2012-2015 to 25% for those diagnosed in 2022-2023. In contrast, the proportion with prolonged wait times — defined as 30 days or longer — increased from 56% to 75%.
Median time from diagnosis to first-course treatment increased significantly (P < .001 for all) between 2012-2015 and 2022-2023 for individuals with all cancer types analyzed:
- breast cancer: 34 days (interquartile range [IQR], 22-50) to 45 days (IQR, 32-64);
- colon cancer: 20 days (IQR, 7-34) to 31 days (IQR, 15-49);
- esophageal cancer: 38 days (IQR, 27-54) to 48 days (IQR, 35-66);
- gastric cancer: 35 days (IQR, 21-51) to 49 days (IQR, 33-70);
- lung cancer: 41 days (IQR, 27-60) to 53 days (IQR, 35-77); and
- pancreatic cancer: 23 days (IQR, 14-35) to 32 days (IQR, 22-44).
Wait times increased among patients who underwent upfront surgery and those who received neoadjuvant therapy.
Results showed consistently longer delays for patients treated at academic or research institutions than community hospitals or integrated network programs.
Among patients diagnosed in 2022-2023, investigators reported consistently shorter median waiting times at community hospitals than integrated network centers or academic institutions for breast cancer (43 days vs. 45 days vs. 49 days), colon cancer (28 days vs. 31 days vs. 35 days) and gastric cancer (46 days vs. 47 days vs. 51 days).
In that same timeframe, results showed shorter wait times at integrated network programs than community programs or academic institutions for lung cancer (51 days vs. 53 days vs. 54 days), esophageal cancer (46 days vs. 47 days vs. 50 days) and pancreatic cancer (31 days vs. 32 days vs. 32 days).
Patients referred for treatment experienced significantly longer waiting times to first-course treatment for all cancer types analyzed, with the longest waits among those referred to high-volume hospitals.
Risk-adjusted analyses identified multiple other factors associated with longer wait times.
Several of them — treatment at academic centers vs. community hospitals, treatment in the West or Northeast regions of the U.S. vs. the Midwest, higher comorbidity burden, lowest income quartile vs. highest income quartile, and more recent diagnosis year — remained consistent across all cancer types analyzed.
Factors that predicted longer wait times for at least half of cancers analyzed included Medicaid insurance (five of six), Black race compared with white race (five of six), greater travel distance (four of six), and uninsured status vs. private insurance (three of six).
Researchers also reported longer waiting times for patients with nonbreast malignancies who underwent robotic surgery.
‘An unacceptable delay’
The percentage of patients who experienced prolonged delays — 30 days or more from diagnosis — increased from 2012-2015 to 2022-2023 for all six malignancies analyzed:
- Breast cancer: 59% to 78%;
- colon cancer: 31% to 52%;
- esophageal cancer: 68% to 84%;
- gastric cancer: 60% to 79%;
- lung cancer: 69% to 83%; and
- pancreatic cancer: 35% to 55%.
The percentage of patients who experienced extreme delays — defined as 60 days or more from diagnosis — also increased from 2012-2015 to 2022-2023 for all cancer types:
- breast cancer: 19% to 32%;
- colon cancer: 7% to 16%;
- esophageal cancer: 17% to 30%;
- gastric cancer: 18% to 35%;
- lung cancer: 26% to 41%; and
- pancreatic cancer: 7% to 12%.
“For the most common cancer types, the benchmark we aim for is to start treatment — whether it be surgery, radiation therapy or chemotherapy — within 4 weeks of diagnosis,” Donahue said. “Sixty days is an extremely long time. Whether that is due to the physicians or the healthcare system, I would say that is an unacceptable delay.”
Patients who had greater comorbidity burden had higher odds for prolonged or extreme waiting periods.
Black patients and those with Medicaid insurance had higher odds for prolonged delays (all cancer types except gastric cancer) and extreme delays (all cancers analyzed) than white patients and those with private insurance. Those in the lowest income quartile had higher likelihood for extreme delays than those in the highest quartile, with that trend persisting across all cancer types analyzed.
“The potential inefficiencies associated with healthcare consolidation can be particularly impactful for patients from under-resourced communities or disadvantaged backgrounds,” Donahue said. “It may be more challenging for them to get to larger centers — which may be farther away — or navigate a complex healthcare system to set up appointments, get their medical records, and provide their imaging or biopsy results. A few days or a week here or there adds up to a long delay, which means disparities could be widening even more.”
Impact and solutions
Researchers acknowledged study limitations, such as inclusion of Commission on Cancer-accredited hospitals only — limiting generalizability of the findings to other settings — and the fact that the National Cancer Database does not capture information about explanations for treatment delays.
It is unclear whether patient preference, desire for second opinions or scheduling constraints may have contributed to delays. Also, the study characterized waiting times but did not explore the potential impact of treatment delays on oncologic outcomes.
“We don’t know from this study whether a delay of a couple of weeks affects prognosis, and that is an important distinction,” Donahue said. “But cancer does not stand still, so unnecessary delays are something we should try to minimize. There is also an important psychological aspect. Delays absolutely contribute to patient anxiety. When I see a patient with a new cancer diagnosis, they tell me they want the thing out yesterday. I can only imagine what it must be like to wait 4 weeks or more, so it is our responsibility to figure out ways to minimize these delays.”
Multidisciplinary care does not inherently have to slow treatment down, Donahue added. “Well-designed multidisciplinary clinics or integrated practice units can bring the necessary specialists together at the same time, rather than requiring patients to navigate a series of sequential appointments,” he said. “The challenge is preserving the benefits of multidisciplinary decision-making without adding unnecessary steps between diagnosis and treatment.”
One solution could be greater adoption of the integrated network program model. The Commission on Cancer offers this organizational accreditation to multifacility healthcare systems that operate under a centralized governance structure and provide coordinated care across multiple locations.
“The integrated network model is interesting because it appears to be associated with shorter delays for some cancers,” Donahue said. “That gets at the concept of regionalization and suggests that health systems should analyze how they organize care internally, directing the most complex cases to centers with the greatest expertise while providing other cancer care closer to home. That may be one way to reduce delays from diagnosis to treatment.”
Establishing benchmarks for timeliness of cancer care also could help health systems identify opportunities for improvement, Donahue said.
“Another opportunity is to develop meaningful benchmarks for timeliness of cancer care,” he said. “We measure many aspects of cancer quality, but we have not focused nearly as much on the time from diagnosis to treatment. The appropriate benchmark will differ by cancer type and treatment pathway, so we first need consensus around what constitutes an acceptable interval. But once those standards are established, organizations such as the Commission on Cancer could potentially use national data to help institutions benchmark their timeliness against national performance and identify where delays are occurring.”
Workforce considerations — such as having additional staff to help patients access and navigate the healthcare system and streamline “somewhat archaic” processes, also could help, Donahue said.
“Cancer care is improving. It is much more advanced and, with consolidation to larger centers, more patients are receiving state-of-the-art care,” he said. “However, as cancer care becomes more advanced, it also becomes more complex. We need to continue to advance the treatments we offer, but we also must be incredibly mindful about how we are going to mitigate the delays from diagnosis to treatment.”
For more information:
Timothy R. Donahue, MD, can be reached at trd4009@med.cornell.edu.
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