ABSTRACT

Objective.

To identify the managerial actions proposed and employed to reduce the waiting time to initiate oncological treatments in the public health system and its application in Latin America.

Method.

We searched seven databases in December 2020. Search terms were conceptualized into three groups: waiting time, cancer, and terms related to public sector. The eligibility criteria included theoretical or empirical academic articles written in English, Spanish, or Portuguese, that focused on managerial solutions to face oncological healthcare queues' dilemma.

Results.

The search returned 1 255 articles, and 20 were selected and analysed in this review. Results show that most of the proposals are related to the process and people dimensions. The actions related to the process dimension were mainly associated with programming new treatment pathways and integrating cancer systems. People's dimension initiatives referred mostly to task forces and groups of specialists. Some initiatives were related to implementing technological solutions and the technology dimension, mainly concerning radiotherapy devices' acquisition.

Conclusion.

Few studies focus on analysing actions to minimize waiting time to initiate oncological treatments. The prevalence of conceptual and illustrative case studies indicates the lack of research maturity on this theme. Future studies should focus on setting the field's theoretical foundations, considering the existing paradigms, or developing new ones. There is a need for empirical studies applying a multidisciplinary approach to face the oncological treatment waiting time challenge and proposing new and innovative initiatives.

Keywords
Waiting lists; cancer; neoplasm; delivery of health care

RESUMEN

Objetivo.

Identificar las medidas gerenciales propuestas y empleadas para reducir el tiempo de espera para iniciar el tratamiento oncológico y su aplicación en el sistema público de salud en América Latina.

Método.

Se realizaron búsquedas en siete bases de datos en diciembre del 2020. Se conceptualizaron los términos de búsqueda en tres grupos: tiempo de espera, cáncer y términos relacionados con el sector público. Entre los criterios de aceptabilidad se incluyeron artículos académicos teóricos o empíricos escritos en inglés, español o portugués acerca de soluciones gerenciales para enfrentar el dilema de los tiempos de espera en la atención médica oncológica.

Resultados.

La búsqueda arrojó como resultado 1 255 artículos; para esta revisión se seleccionaron y analizaron 20. Los resultados muestran que la mayoría de las propuestas están relacionadas con dos dimensiones: el proceso y los pacientes. Las medidas relacionadas con el proceso se asociaron principalmente con la planificación de nuevas vías de tratamiento y la integración de los sistemas oncológicos. Las iniciativas relacionadas con los pacientes se referían principalmente a equipos de trabajo y grupos de especialistas. Algunas iniciativas estuvieron relacionadas con la dimensión de tecnología y soluciones tecnológicas, principalmente con la compra de equipos de radioterapia.

Conclusiones.

Pocos estudios se centran en analizar medidas que minimicen el tiempo de espera para iniciar los tratamientos oncológicos. La prevalencia de estudios de casos conceptuales e ilustrativos indica la falta de madurez de la investigación sobre este tema. Los estudios futuros deben centrarse en establecer las bases teóricas del campo, considerar los paradigmas existentes o elaborar nuevos paradigmas. Es necesario realizar estudios empíricos que apliquen un enfoque multidisciplinario para afrontar el reto del tiempo de espera para recibir tratamiento oncológico y que propongan iniciativas nuevas e innovadoras.

Palabras clave
Listas de espera; cáncer; neoplasias; atención a la salud

RESUMO

Objetivo.

Identificar ações gerenciais propostas e adotadas para reduzir o tempo de espera para o início do tratamento oncológico no sistema de saúde pública e sua aplicação na América Latina.

Método.

Foram feitas buscas em sete bancos de dados em dezembro de 2020. Os termos de busca foram conceituados em três grupos: tempo de espera, câncer e termos relacionados ao setor público. Os critérios de elegibilidade incluíam artigos acadêmicos teóricos ou empíricos escritos em inglês, espanhol ou português, cujo foco fossem soluções gerenciais para enfrentar o dilema das filas para atendimento oncológico.

Resultados.

A busca retornou 1255 artigos, dos quais 20 foram selecionados e analisados nesta revisão. Os resultados mostram que a maioria das propostas está relacionada às dimensões de processo e pessoas. As ações relacionadas à dimensão de processo estavam associadas principalmente ao desenvolvimento de novos percursos assistenciais e à integração dos sistemas de atendimento oncológico. Já as iniciativas na dimensão de pessoas se referiam principalmente a forças-tarefa e grupos de especialistas. Algumas iniciativas estavam relacionadas à implementação de soluções tecnológicas e à dimensão tecnológica, sobretudo no que se refere à aquisição de dispositivos de radioterapia.

Conclusão.

Poucos estudos se concentram na análise de ações para minimizar o tempo de espera para início do tratamento oncológico. A prevalência de estudos de caso conceituais e ilustrativos indica a falta de maturidade da pesquisa sobre esse tema. Futuros estudos devem se concentrar em definir fundamentos teóricos da área, considerar os paradigmas existentes ou desenvolver novos paradigmas. São necessários estudos empíricos que utilizem uma abordagem multidisciplinar para enfrentar o desafio do tempo de espera para o tratamento oncológico e que proponham iniciativas novas e inovadoras.

Palavras-chave
Listas de espera; câncer; neoplasias; atenção à saúde

Cancer incidence and mortality are rapidly growing worldwide, most markedly in the low- and middle-income countries (LMICs) (¹1. Ferlay J, Colombet M, Soerjomataram I, Mathers C, Parkin DM, Piñeros M, et al. Estimating the global cancer incidence and mortality in 2018: GLOBOCAN sources and methods. Int J Cancer. 2018; 144(8):1941–53. doi: 10.1002/ijc.31937
https://doi.org/10.1002/ijc.31937... ). The latest worldwide estimation, from 2018, points out that 18 million new cases of cancer have occurred in the world (²2. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018;68(6):394–424. doi: 10.3322/caac.21492
https://doi.org/10.3322/caac.21492... ). The reasons are complex but reflect both aging and growth of the population and changes in the prevalence and distribution of the main risk factors for cancer (³3. World Health Organization. Global health observatory. Geneva: WHO; 2018. Available from: https://www.who.int/data/gho. Accessed 10 December 2021.
https://www.who.int/data/gho... ). Managing cancer requires both effective preventive measures – to reduce future burden of disease – and healthcare systems that provide accurate diagnosis and high-quality multimodality treatment. Such multimodality treatment should include radiotherapy, surgery, drugs, and access to palliative and supportive care (⁴4. National Comprehensive Cancer Network. Guidelines [Internet]. Plymouth Meeting: NCCN; 2021. Available from: https://www.nccn.org/professionals/physician_gls/pdf/palliative.pdf. Accessed 10 December 2021.
https://www.nccn.org/professionals/physi... ).

Delay in the treatment of cancer can have adverse consequences on outcome. Previous meta-analyses have found evidence supporting a continuous association between delay and mortality or local control (⁵5. Biagi JJ, Raphael MJ, Mackillop WJ, Kong W, King WD, Booth CM. Association Between Time to Initiation of Adjuvant Chemotherapy and Survival in Colorectal Cancer. JAMA. 2011;8;305(22):2335. doi: http://dx.doi.org/10.1001/jama.2011.749.
http://dx.doi.org/10.1001/jama.2011.749... –⁸8. Graboyes EM, Kompelli AR, Neskey DM, Brennan E, Nguyen S, Sterba KR, et al. Association of Treatment Delays with Survival for Patients with Head and Neck Cancer. JAMA Otolaryngol–Head Neck Surg. 2019;1;145(2):166. doi: http://dx.doi.org/10.1001/jamaoto.2018.2716
http://dx.doi.org/10.1001/jamaoto.2018.2... ).

A recent publication (⁹9. Hanna TP, King WD, Thibodeau S, Jalink M, Paulin GA, Harvey-Jones E, et al. Mortality due to cancer treatment delay: systematic review and meta-analysis. BMJ. 2020;371:m4087. doi: https://doi.org/10.1136/bmj.m4087
https://doi.org/10.1136/bmj.m4087... ) found that a four-week delay in treatment is associated with an increase in mortality across all forms of cancer treatment, with longer delays being increasingly detrimental.

Advanced stage presentation of patients with cancer is common in LMICs (¹⁰10. Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin. 2021;71(3):209-249. doi: 10.3322/caac.21660.
https://doi.org/10.3322/caac.21660... ). Studies from low-income countries had significantly longer access intervals (median 6,5 months) compared with other income groups (¹¹11. Brand NR, Qu LG, Chao A, Ilbawi AM. Delays and Barriers to Cancer Care in Low- and Middle-Income Countries: A Systematic Review. Oncologist. 2019;24(12):e1371-e1380. doi: 10.1634/theoncologist.2019-0057
https://doi.org/10.1634/theoncologist.20... ).

Much has been written about the need for a comprehensive approach to population-based cancer control and challenges related to allocating scarce resources to treat cancer (¹²12. Wang F, Luo L, McLafferty S. Healthcare access, socioeconomic factors and late-stage cancer diagnosis: an exploratory spatial analysis and public policy implication. Int J Public Pol. 2010;5(2/3):237-58. doi: 10.1504/ijpp.2010.030606
https://doi.org/10.1504/ijpp.2010.030606... , ¹³13. Maruthappu M, Watkins J, Noor AM, Williams C, Ali R, Sullivan R, et al. Economic downturns, universal health coverage, and cancer mortality in high-income and middle-income countries, 1990–2010: a longitudinal analysis. Lancet. 2016;388(10045):684–95. doi: 10.1016/s0140-6736(16)00577-8
https://doi.org/10.1016/s0140-6736(16)00... ). In summary, there are two groups of potential risks to late-stage cancer treatment: access to healthcare and socioeconomic and demographic characteristics (¹⁴14. Alves MO, Magalhães SCM, Coelho BA. A regionalização da saúde e a assistência aos usuários com câncer de mama. Saúde Soc. 2017;26(1):141–54. doi:10.1590/s0104-12902017160663
https://doi.org/10.1590/s0104-1290201716... ). The former emphasizes spatial elements and accounts for the complex interaction between primary healthcare supply and demand locations and the distance and ease to travel between them. On the non-geographic factors, socioeconomic disadvantages and socio-cultural barriers also play a role.

Therefore, the need for an in-depth understanding of the managerial actions to reduce the waiting time to initiate oncological treatments in the public health system is coming rapidly into focus as well as its application in Latin America. More broadly, this review analyses and classifies the actions and recommendations in three dimensions: people, process, technology. These dimensions (PPT model) have been widely recognized as the three elements which underlie process improvement (¹⁵15. Leavitt HJ. Applied organisational change in industry: Structural, technological and humanistic approaches. In: March JG, editor. Handbook of Organisation. New York: Rand McNally; 1965.). The model is also about how the three elements interact. People do the work and processes make this work more efficient. Technology helps people do their tasks and also helps automate the processes. Thus, organizational efficiency can be achieved by balancing the three and optimizing the relationships between people, processes and technology.

The first dimension – people – looks after the 'human' dimension, including people with the right skills and knowledge for the job and motivation and engagement to achieve higher performances. The process dimension refers to the set of interrelated work activities that transforms inputs into outputs. It is essential to analyze the process, identify waste and eliminate it to deliver what is expected efficiently. The third dimension – technology – addresses the tools and techniques used to communicate and make work efficient. It includes information management systems and their architectures, hardware, and software. Technology is facilitated by people and is supporting the processes to run smoothly. This theoretical model sustains the management functions, and its application can boost the overall system's performance.

We also analyzed the initiatives considering the conceptualization of health service ecosystems (¹⁶16. Beirão G, Patrício L, Fisk RP. Value cocreation in service ecosystems. J Serv Manag. 2017;28(2):227–49. doi:10.1108/josm-11-2015-0357
https://doi.org/10.1108/josm-11-2015-035... , ¹⁷17. Chandler JD, Vargo SL. Contextualization and value-in-context: How context frames exchange. Marketing Theory. 2011;11(1):35–49. doi:10.1177/1470593110393713
https://doi.org/10.1177/1470593110393713... ): micro-, meso-, or macro-level. The micro level comprises the individual actors such as health professionals, patients, or family. Value cocreation factors at this level enable dyadic interactions through which individual actors integrate resources to co-create value with other actors. Individuals engage in collaborative and cooperative interactions (¹⁶16. Beirão G, Patrício L, Fisk RP. Value cocreation in service ecosystems. J Serv Manag. 2017;28(2):227–49. doi:10.1108/josm-11-2015-0357
https://doi.org/10.1108/josm-11-2015-035... ). The meso level consists of public and private hospitals, primary care units, and health support organizations. At this level, the facilitation of collaboration and cooperation between different health institutions enables delivering better health services. Lastly, the macro level actors include government, the ministry of health, and other organizations responsible for defining national health policies (¹⁶16. Beirão G, Patrício L, Fisk RP. Value cocreation in service ecosystems. J Serv Manag. 2017;28(2):227–49. doi:10.1108/josm-11-2015-0357
https://doi.org/10.1108/josm-11-2015-035... ). At the macro level, value cocreation factors are related mainly to resource access. In this review, the micro level comprises actions directed to health professional actors. The meso level embraces activities focused on health institutions, like hospitals or clinics. Finally, the macro level contains efforts directed to the government and healthcare authorities.

The purpose of this study is to identify the managerial actions proposed and employed to reduce the waiting time to initiate oncological treatments in the public health system and its application in Latin America. Our analysis aims to provide a comprehensive overview of existing literature about managing cancer care intervals and identify targets for future interventions to barriers. These findings will ultimately inform future research in cancer early treatment and bring evidence to guide strategies making.

METHODS

A systematic review was performed following the PRISMA protocol, adopting a replicable, scientific, and transparent literature data search, management, and analysis process (¹⁸18. Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. Ann Intern Med. 2009;151(4):264-9. doi:10.7326/0003-4819-151-4-200908180-00135
https://doi.org/10.7326/0003-4819-151-4-... ). The search was performed in December 2020, including articles published up to that date, across databases that cover international content in the fields of management and healthcare: EBSCO, SCOPUS, Web of Science, Proquest, PubMed, Emerald, and the Virtual Health Library (VHL). The search strategy included combined terms using the Boolean operators ‘AND’ and “OR”: ("public sector" OR "public administration" OR "public organization*" OR "public organisation*" OR "public agenc*" OR "public institution*" OR "public service*" OR "public health" OR "public policy" OR "public policies" AND ("waiting lists" OR "waiting line*" OR "waiting time") AND (“neoplasm*” OR “cancer” OR “oncolog*"). These terms should be present in the title, abstract or keywords of the analyzed articles. Table 1 presents the corresponding number of articles obtained in each database.

The eligibility criteria limited the nature of texts to academic articles, with full online texts available, written in either English, Spanish or Portuguese. We did not apply filters regarding the type of publication, the research method, the year of publication, or the journal’s impact factor.

A standardized Microsoft Excel spreadsheet was used to analyse the studies, considering the following categories: (¹1. Ferlay J, Colombet M, Soerjomataram I, Mathers C, Parkin DM, Piñeros M, et al. Estimating the global cancer incidence and mortality in 2018: GLOBOCAN sources and methods. Int J Cancer. 2018; 144(8):1941–53. doi: 10.1002/ijc.31937
https://doi.org/10.1002/ijc.31937... ) Authors and year of publication; (²2. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018;68(6):394–424. doi: 10.3322/caac.21492
https://doi.org/10.3322/caac.21492... ) Journal of publication and its impact factor; (³3. World Health Organization. Global health observatory. Geneva: WHO; 2018. Available from: https://www.who.int/data/gho. Accessed 10 December 2021.
https://www.who.int/data/gho... ) Country of research; (⁴4. National Comprehensive Cancer Network. Guidelines [Internet]. Plymouth Meeting: NCCN; 2021. Available from: https://www.nccn.org/professionals/physician_gls/pdf/palliative.pdf. Accessed 10 December 2021.
https://www.nccn.org/professionals/physi... ) Type of neoplasm investigated; (⁵5. Biagi JJ, Raphael MJ, Mackillop WJ, Kong W, King WD, Booth CM. Association Between Time to Initiation of Adjuvant Chemotherapy and Survival in Colorectal Cancer. JAMA. 2011;8;305(22):2335. doi: http://dx.doi.org/10.1001/jama.2011.749.
http://dx.doi.org/10.1001/jama.2011.749... ) Research objective; (⁶6. Raphael MJ, Biagi JJ, Kong W, Mates M, Booth CM, Mackillop WJ. The relationship between time to initiation of adjuvant chemotherapy and survival in breast cancer: a systematic review and meta-analysis. Breast Cancer Res Treat. 2016;160(1):17–28. doi: http://dx.doi.org/10.1007/s10549-016-3960-3
http://dx.doi.org/10.1007/s10549-016-396... ) Research method: empirical/qualitative (case studies, interview-based studies, and action research), empirical/quantitative (survey-based studies), mathematical modelling, and mixed methods; (⁷7. Chen Z, King W, Pearcey R, Kerba M, Mackillop WJ. The relationship between waiting time for radiotherapy and clinical outcomes: A systematic review of the literature. Radiother Oncol. 2008;87(1):3–16. doi: http://dx.doi.org/10.1016/j.radonc.2007.11.016
http://dx.doi.org/10.1016/j.radonc.2007.... ) Classification in one or more of the three dimensions: people, process or technology; and (⁸8. Graboyes EM, Kompelli AR, Neskey DM, Brennan E, Nguyen S, Sterba KR, et al. Association of Treatment Delays with Survival for Patients with Head and Neck Cancer. JAMA Otolaryngol–Head Neck Surg. 2019;1;145(2):166. doi: http://dx.doi.org/10.1001/jamaoto.2018.2716
http://dx.doi.org/10.1001/jamaoto.2018.2... ) Classification in one or more of the three levels (macro, meso, or micro) of the service ecosystems.

RESULTS

The search resulted in a total of 1 255 articles that were imported into the software Mendeley^®, where 59 duplicates were removed. The 1 196 remaining articles were exported into Rayyan.com software. Both authors independently reviewed titles and abstracts to identify articles related to waiting time for oncological treatment in the public sector. We excluded 101 theoretical articles not related to the theme. In the next stage, the two authors independently conducted a full article assessment, following the pre-specified inclusion criteria, and labeling the articles according to an ABC categorization, in terms of its adequacy with the research objectives: (A) inside the scope; (B) doubt, or (C) outside the scope. Disagreements were discussed among the two authors to increase the reliability of the process selection. In the end, there were 1 077 studies categorized as ‘out of scope’ and 18 inside the scope. Next, the authors applied the snowball strategy to screen reference lists of selected studies, looking for potentially relevant studies. Through this process, we identified two additional papers, resulting in 20 articles analyzed in this review. Figure 1 presents the PRISMA protocol applied in this research to identify, assess, and select existing studies (¹⁸18. Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. Ann Intern Med. 2009;151(4):264-9. doi:10.7326/0003-4819-151-4-200908180-00135
https://doi.org/10.7326/0003-4819-151-4-... ).

Studies characteristics

The 20 selected studies were published between 2006 and 2019 (Table 2). Regarding the research country, the most frequent was the United States (6/20; 30%). However, 30% (6/20) of the studies were from low- and middle-income countries (LMIC). The studies were published in different scholarly journals. Four studies were published in journals with an impact factor (IF) higher than 30, and the median IF was 2,69. Most of the articles (17/20, 85%) were published in healthcare journals, and 15% (3/20) were published in management journals.

Regarding the methodology, there was a predominance of mathematical modelling studies, accounting for 35% of the sample (7/20 studies). There were six qualitative studies (30%), three quantitative studies (15%), and only four studies (20%) adopted a mixed-method approach. Table 2 provides a detailed analysis of the selected publications.

Managerial practices applied to reduce waiting time to initiate cancer treatment

About the categorization in the three dimensions (people, process, and technology), process was a dimension addressed in almost all studies (19/20, 95.0%) (Table 3). People was the second most addressed (18/20, 90.0%), and the dimension ‘technology’ was present in only 11 studies (55.0%).

Concerning the initiative level, most studies addressed the macro (government actions) and the meso level (case reports from health services), present in 11 studies each (55%). The micro level (individual actors) was present in only 8 publications (40%).

It was possible to identify the different levels of actions and their aggregation in the PPT dimensions. We combined the occurrences in a 3×3 matrix (Table 4), illustrating how many times each dimension and each level was present simultaneously in a publication.

Most of the proposed actions to reduce the waiting time for initiate cancer treatment have been directed at improving processes (29/72; 40.2%), followed by activities focused on people (27/72; 37.5%). A smaller number of proposed initiatives is related to introducing new technologies (technology dimension), present in only 22.2% of the studies (16/72).

Regarding the level of actors involved in the proposed actions, most studies focus on healthcare organizations (meso level), present in 40.3% of the initiatives (29/72). In second place are government actions (national, macro level), present in 31.9% of the initiatives (23/72). Finally, there are actions addressing specialists, patients, and doctors, representing 27.7% of the proposed actions (20/72).

Government actions (macro level) have been aimed at improving processes (10/23; 43.4%), followed by efforts directed at people (8/23; 34.7%), and a smaller number of actions related to the introduction of new technologies (5/23; 21.7%). In turn, the initiatives implemented at the meso level have been directed equally towards processes (11/29; 37.9%) and people (11/29; 37.9%), while there are a smaller number of actions related to technological solutions (7/29; 24.1%). Likewise, micro-level efforts are generally directed towards processes (8/20; 40.0%) or people (8/20; 40.0%), with only four articles mentioning the implementation of technology (4/20; 20.0%).

Few studies have brought the results reached with their proposals (²⁴24. Hunnibell LS, Rose MG, Connery DM, Grens CE, Hampel JM, Rosa M, et al. Using Nurse Navigation to Improve Timeliness of Lung Cancer Care at a Veterans Hospital. Clin J Oncol Nurs. 2012;16(1):29–36. doi: 10.1188/12.cjon.29-36
https://doi.org/10.1188/12.cjon.29-36... , ²⁶26. Alsamarai S, Yao X, Cain HC, Chang BW, Chao, HH, Connery DM, et al. The effect of a lung cancer care coordination program on timeliness of care. Clin Lung Cancer. 2013;14(5):527–34. doi: 10.1016/j.cllc.2013.04.004
https://doi.org/10.1016/j.cllc.2013.04.0... , ²⁷27. Singh J, Edge SB, Bonaccio E, Schwert KT, Braun B. Breast cancer center: improving access to patient care. J Natl Compr Canc Netw. 2014;12 (Suppl. 1):S28–S32. doi: 10.6004/jnccn.2014.0211
https://doi.org/10.6004/jnccn.2014.0211... , ³²32. Job M, Holt T, Bernard A. Reducing radiotherapy waiting times for palliative patients: The role of the Advanced Practice Radiation Therapist. J Med Radiat Sci. 2017;64(4):274–80. doi: 10.1002/jmrs.243
https://doi.org/10.1002/jmrs.243... , ³⁵35. Moore A, Villalobos A, Gardner AL, Staples C, Shafir S. Leveraging the strength of comprehensive cancer control coalitions to support policy, systems, and environmental change. Cancer Causes Control. 2019;30(10):1033–44. doi: 10.1007/s10552-019-01215-w
https://doi.org/10.1007/s10552-019-01215... , ³⁶36. Common JL, Mariathas HH, Parsons K, Greenland JD, Harris S, Bhatia R, et al. Reducing Wait Time for Lung Cancer Diagnosis and Treatment: Impact of a Multidisciplinary, Centralized Referral Program. Can Assoc Radiol J. 2018;69(3):322–7. doi: 10.1016/j.carj.2018.02.001
https://doi.org/10.1016/j.carj.2018.02.0... , ³⁸38. Blackmore KM, Weerasinghe A, Holloway CMB, Majpruz V, Mirea L, O’Malley FP, et al. Comparison of wait times across the breast cancer treatment pathway among screened women undergoing organized breast assessment versus usual care. Can J Public Health. 2019;110(5):595–605. doi: 10.17269/s41997-019-00210-7
https://doi.org/10.17269/s41997-019-0021... ). Shorter average waiting times from suspicion of cancer to treatment and an improve timeliness in cancer care was achieved in those publications.

DISCUSSION

This systematic review describes the managerial actions proposed and employed to reduce the waiting time to initiate oncological treatments in the public health system. It presents the largest sample of studies to date, investigating actions to diminish intervals and barriers to cancer care. It presents the published literature by the three dimensions of process improvement (people, process, and technology) and also by the ecosystem level perspective (macro, micro, or meso).

There are previous literature reviews conducted about the theme. Sharma et al. (³⁹39. Sharma K, Costas A, Shulman LN, Meara JG. A systematic review of barriers to breast cancer care in developing countries resulting in delayed patient presentation. J Oncol. 2018;2012:1–8. doi: 10.1155/2012/121873
https://doi.org/10.1155/2012/121873... ) explored the barriers to breast cancer care in developing countries resulting in delayed patient presentation. Unger-Saldaña (⁴⁰40. Unger-Saldaña K. Challenges to the early diagnosis and treatment of breast cancer in developing countries. World J Clin Oncol. 2014;5(3):465-77. doi: 10.5306/wjco.v5.i3.465
https://doi.org/10.5306/wjco.v5.i3.465... ) found that research on specific barriers to access and deficiencies in the quality of care for the early diagnosis and treatment of breast cancer is practically non-existent. Ginsburg et al. (²⁸28. Ginsburg O, Badwe R, Boyle P, Derricks G, Dare A, Evans T, et al. Changing global policy to deliver safe, equitable, and affordable care for women’s cancers. Lancet. 2017;389(10071):871–80. doi: 10.1016/s0140-6736(16)31393-9
https://doi.org/10.1016/s0140-6736(16)31... ) explored the global health and public policy landscapes that intersect with women's health and global cancer control, with new approaches to bringing policy to action.

This review demonstrates that delays are a major concern during every step of the cancer care continuum, across different cancer types and country income levels. Treatment delays could be due to patient factors, disease factors or system factors. The main purpose of this discussion is to highlight the need to minimize system level delays.

A major finding in this study is the paucity of high-quality data providing the impact of interventions in treatment initiation in their settings. Furthermore, we found considerable heterogeneity in the metrics used by studies to describe the results obtained, considering the different health care systems where the proposals were made and the years of publication.

Although the number of studies is limited, there may be opportunities to learn about successful interventions that decrease diagnostic and treatment intervals. As we assume that those gaps are significantly longer in Latin America, these findings suggest that studies focusing on treatment delays in LMICs are profoundly needed, the targeted programs that address barriers to primary care should be prioritized.

As shown in Table 4, it is interesting to note that despite the great technological advances and digital transformation present in most organizations, few initiatives propose using technology to improve the process and reduce the waiting time for cancer treatment. In this sense, government actions could seek to invest in technology to integrate and enhance cancer treatment processes. Likewise, healthcare organizations (meso level) could take advantage of new technologies to reduce patients' waiting for treatment.

The large variability in the interventions proposed complicates comparisons across the studies. However, it was possible to divide the initiatives into three main strategic levels: public policies (macro level), institutional planning and coordinating (meso level), and people engagement (micro level). It was also possible to classify the proposed solutions in each PPT dimension: Process dimension – prototyping with creative ways to minimize delays; People dimension – training professionals and foment team working; Technology dimension – investing in technology and new equipment.

Strategic level of the initiatives

Public policies strategies – Macro level.

Results indicate that governments should implement large-scale programs to define and build new services infrastructure, train healthcare professionals and paraprofessionals, and invest in technology, especially in telecommunication, to overcome many on-site limitations in resources and expand access to health services (¹⁰10. Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin. 2021;71(3):209-249. doi: 10.3322/caac.21660.
https://doi.org/10.3322/caac.21660... , ²⁶26. Alsamarai S, Yao X, Cain HC, Chang BW, Chao, HH, Connery DM, et al. The effect of a lung cancer care coordination program on timeliness of care. Clin Lung Cancer. 2013;14(5):527–34. doi: 10.1016/j.cllc.2013.04.004
https://doi.org/10.1016/j.cllc.2013.04.0... ). These initiatives are critical in low and middle-income countries.

Governments should also design and implement regional and global pricing and procurement mechanisms to offer individual communities the opportunity to participate in collective negotiation and ensure reduced prices for essential services, drugs, and vaccines (²³23. Farmer P, Frenk J, Knaul FM, Shulman LN, Alleyne G, Armstrong L, et al. Expansion of cancer care and control in countries of low and middle income: a call to action. Lancet. 2010;376(9747):1186–93. doi: 10.1016/s0140-6736(10)61152-x
https://doi.org/10.1016/s0140-6736(10)61... ). Lastly, governments should identify and implement innovative financing mechanisms to expand the financial resources available for cancer treatment and palliative care in developing countries (⁴¹41. Ferreira NAS, Schoueri JHM, Sorpreso ICE, Adami F, Santos Figueiredo FW. Waiting Time between Breast Cancer Diagnosis and Treatment in Brazilian Women: An Analysis of Cases from 1998 to 2012. Int J Environ Res Public Health. 2020;17(11):4030. doi: 10.3390/ijerph17114030
https://doi.org/10.3390/ijerph17114030... ).

Public policy efforts are increasingly recognized as critical to eliminate cancer disparities (²⁸28. Ginsburg O, Badwe R, Boyle P, Derricks G, Dare A, Evans T, et al. Changing global policy to deliver safe, equitable, and affordable care for women’s cancers. Lancet. 2017;389(10071):871–80. doi: 10.1016/s0140-6736(16)31393-9
https://doi.org/10.1016/s0140-6736(16)31... ). For example, there are racial and ethnic disparities regarding treatment and survival. Rural residents often have higher cancer incidence and mortality than urban residents, and there are documented disparities related to cancer diagnosis and treatment in rural areas. Individuals with disabilities have unique challenges related to access and may face transportation problems to get to the clinics. As a result, people with disabilities have lower cancer screening rates, are diagnosed later, and have a lower survival rate than people without disabilities.

Planning and Coordinating Strategies – Meso level.

Integrated care means bringing together all the inputs necessary to deliver the diagnosis, treatment, care, rehabilitation, and health promotion. It is a means of improving access, quality of care, user satisfaction, and efficiency (⁴²42. Gröne O, Garcia-Barbero M, WHO European Office for Integrated Health Care Services. Integrated care: a position paper of the WHO European Office for Integrated Health Care Services. Int J Integr Care. 2001;1(1):1-10. doi: 10.5334/ijic.28
https://doi.org/10.5334/ijic.28... ). The vertical integration of cancer care services presents an enormous challenge. Still, it offers an exciting opportunity to radically transform the provision of cancer services through creating a holistic model spanning organizational boundaries and placing the patient at the heart of the system (³⁹39. Sharma K, Costas A, Shulman LN, Meara JG. A systematic review of barriers to breast cancer care in developing countries resulting in delayed patient presentation. J Oncol. 2018;2012:1–8. doi: 10.1155/2012/121873
https://doi.org/10.1155/2012/121873... ). Therefore, it is crucial to expand collaboration to build efficient healthcare systems for cancer and primary care, surgery, pathology, chemotherapy, and radiotherapy (³⁴34. Swanson M, Ueda S, Chen L, Huchko MJ, Nakisige C, Namugga J. Evidence-based improvisation: Facing the challenges of cervical cancer care in Uganda. Gynecol Oncol Rep. 2018;24:30–5. doi: 10.1016/j.gore.2017.12.005
https://doi.org/10.1016/j.gore.2017.12.0... ).

According to Unger-Saldaña et al. (⁴⁰40. Unger-Saldaña K. Challenges to the early diagnosis and treatment of breast cancer in developing countries. World J Clin Oncol. 2014;5(3):465-77. doi: 10.5306/wjco.v5.i3.465
https://doi.org/10.5306/wjco.v5.i3.465... ), early integration of palliative and oncology care in patients with newly diagnosed incurable cancers improves the quality of life (QOL), reduces depression symptoms, and enhances coping with prognosis and communication about individual-care preferences. These findings provide further evidence to support early integrated programs as the standard of care for patients with newly diagnosed cancers.

Engagement Strategy – Micro level.

Delays in initiating cancer treatment can occur for two reasons: provider delay (a prolonged interval from patient presentation to first oncologic treatment), or patient delay (a prolonged interval from discovering the disease and searching for a qualified medical provider). Patients' delay can indicate a lack of public awareness regarding the consequences of postponing cancer treatment (³⁰30. Terán-Hernández M. Accesibilidad espacial de los servicios de prevención y control del cáncer-cervicouterino en San Luis Potosí. Invest Geo. 2017;(94):122-37. doi: 10.14350/rig.56936
https://doi.org/10.14350/rig.56936... ). Also, move away from home, family, or work responsibilities to start cancer treatment or pay for the high cost of diagnosis and treatment constitute particularly burdensome problems possibly hindering the beginning of the treatment, mostly in low and middle-income countries). In addition, interventions should also attempt to raise cancer awareness and reduce the stigma of this disease (³⁵35. Moore A, Villalobos A, Gardner AL, Staples C, Shafir S. Leveraging the strength of comprehensive cancer control coalitions to support policy, systems, and environmental change. Cancer Causes Control. 2019;30(10):1033–44. doi: 10.1007/s10552-019-01215-w
https://doi.org/10.1007/s10552-019-01215... ).

PPT Dimensions strategies

Practices related to the Process dimension.

According to organizational theory, solving business problems is a matter of coordination (¹⁹19. Kenis P. Waiting lists in Dutch health care: an analysis from an organization theoretical perspective. J Health Organ Manag. 2006;20(4):294–308. doi: 10.1108/14777260610680104
https://doi.org/10.1108/1477726061068010... ). In most studies, policymakers intended to reduce process fragmentation, improving integration and vertical control (²³23. Farmer P, Frenk J, Knaul FM, Shulman LN, Alleyne G, Armstrong L, et al. Expansion of cancer care and control in countries of low and middle income: a call to action. Lancet. 2010;376(9747):1186–93. doi: 10.1016/s0140-6736(10)61152-x
https://doi.org/10.1016/s0140-6736(10)61... ).

Farmer et al. (²³23. Farmer P, Frenk J, Knaul FM, Shulman LN, Alleyne G, Armstrong L, et al. Expansion of cancer care and control in countries of low and middle income: a call to action. Lancet. 2010;376(9747):1186–93. doi: 10.1016/s0140-6736(10)61152-x
https://doi.org/10.1016/s0140-6736(10)61... ) states that a diagonal approach – in which resources are distributed in ways that strengthen the entire health system – can be applied to cancer. This approach should help identify synergies, link cancer care and control to many services associated with a broad range of medical disorders, reinforce physical infrastructure in health systems, and avoid creating a parallel structure for service delivery.

The studies indicate that early referral of patients with imaging is associated with reduced wait time and more appropriate specialist consultation in diagnosing and treating neoplasms (³⁶36. Common JL, Mariathas HH, Parsons K, Greenland JD, Harris S, Bhatia R, et al. Reducing Wait Time for Lung Cancer Diagnosis and Treatment: Impact of a Multidisciplinary, Centralized Referral Program. Can Assoc Radiol J. 2018;69(3):322–7. doi: 10.1016/j.carj.2018.02.001
https://doi.org/10.1016/j.carj.2018.02.0... ).

Practices related to the People dimension.

The leading healthcare professional's objective is to provide high-quality services to those who need them most. However, the long waiting lists prevent them from providing high-quality service to their patients. In this context, they will presumably give high priority to reducing waiting lists (¹⁹19. Kenis P. Waiting lists in Dutch health care: an analysis from an organization theoretical perspective. J Health Organ Manag. 2006;20(4):294–308. doi: 10.1108/14777260610680104
https://doi.org/10.1108/1477726061068010... ).

An important goal is to train in cancer medicine specialties. As reported by some authors (³³33. Lefresne S, Olson R, Cashman R, Kostuik P, Jiang WN, Levy K, et al. Prospective analysis of patient reported symptoms and quality of life in patients with incurable lung cancer treated in a rapid access clinic. Lung Cancer. 2017;112:35–40. doi: 10.1016/j.lungcan.2017.07.033
https://doi.org/10.1016/j.lungcan.2017.0... , ³⁷37. Jacobson G, Chuang L, Pankow M. Improving quality of care and timely access to radiation therapy for patients with invasive cervical cancer at the National Cancer Institute Paraguay. Gynecol Oncol Rep. 2018;25:82–6. doi: 10.1016/j.gore.2018.06.006
https://doi.org/10.1016/j.gore.2018.06.0... ), patients have better outcomes when treated by specialists. The expert team discusses interventions to improve the existing system and make it more efficient without significant spending. They also focus on developing diagnostic and treatment pathways and reinforcing a multidisciplinary approach.

The creation of tumour boards (panel of specialists), which meet frequently and bring together cancer care coordinators with the care providers, improve the communication among the team, promote better cancer care results, and reduce waiting lines for treatment (²⁴24. Hunnibell LS, Rose MG, Connery DM, Grens CE, Hampel JM, Rosa M, et al. Using Nurse Navigation to Improve Timeliness of Lung Cancer Care at a Veterans Hospital. Clin J Oncol Nurs. 2012;16(1):29–36. doi: 10.1188/12.cjon.29-36
https://doi.org/10.1188/12.cjon.29-36... , ²⁶26. Alsamarai S, Yao X, Cain HC, Chang BW, Chao, HH, Connery DM, et al. The effect of a lung cancer care coordination program on timeliness of care. Clin Lung Cancer. 2013;14(5):527–34. doi: 10.1016/j.cllc.2013.04.004
https://doi.org/10.1016/j.cllc.2013.04.0... ).

Practices related to the Technology dimension.

Approaches on cancer treatment have been making significant technological improvements, moving from practice consistent with a "basic setting" to practice consistent with an "enhanced setting". In this sense, recent technological solutions, including tele-radiotherapy systems, radiological imaging, artificial intelligence, and scheduling models, have been extensively explored (³¹31. Yap ML, Hanna TP, Shafiq J, Ferlay J, Bray F, Delaney GP, et al. The Benefits of Providing External Beam Radiotherapy in Low- and Middle-income Countries. Clin Oncol. 2017;29(2):72–83. doi: 10.1016/j.clon.2016.11.003
https://doi.org/10.1016/j.clon.2016.11.0... ). New approaches in the surgery setting (robotic surgery) also seem to play a role (²¹21. Kawakami J, Hopman WM, Smith-Tryon R, Siemens DR. Measurement of surgical wait times in a universal health care system. Can Urol Assoc J. 2008;2(6):597-603. doi: 10.5489/cuaj.974
https://doi.org/10.5489/cuaj.974... ).

The studies indicate that some actions related to introducing new technology – as a faster turnaround of pathology reports and improved availability of brachytherapy – have decreased the time from diagnosis to treatment and increased the availability of standard care treatment. Also, the transition from 2-D to 3-D treatment planning has moved the practice to more precise radiotherapy, which has resulted in improved outcomes with decreased morbidity (²²22. Shea AM, Curtis LH, Hammill BG, DiMartino LD, Abernethy AP, Schulman KA. Association between the Medicare Modernization Act of 2003 and patient wait times and travel distance for chemotherapy. JAMA. 2008;300(2):189-96. doi: 10.1001/jama.300.2.189
https://doi.org/10.1001/jama.300.2.189... ). (Table 5)

The limitations of this study include the risk of overlooking some key literature, as studies not published in peer-reviewed journals or indexed in electronic databases were excluded; this also includes potentially important literature that may have been undiscovered due to the use of different keywords. In addition, this systematic review focused in the public health system. Thus, any relevant study outside these limits was not considered eligible. Secondly, our findings summarize published studies that reported heterogeneous data of different study designs, quality and varying evidence level and including different health care systems. The selected publications comprised distinct research contexts and methods, thus hindering a statistical meta-analysis. Finally, there might be limitations in terms of identifying trends. Scoping the actions for cancer treatment (and not prevention) may not be sufficient for establishing the direction that the natural process will take. Another question that we faced was the few connections and little interaction between authors, who prefer to collaborate in closed networks. Maybe it would be part of geographical barriers, different types of cancer statistics, and different populations.

In conclusion, our literature review confirms the advantages of using a network lens to understand the development of actions concerning queues in oncology treatments. Our approach indicates network actors and flows between those actors that need further research while underlining the lack of other systematic reviews about the theme.

As a contribution to society, this study shows the increasing attention devoted to alliances and collaboration in oncological healthcare, resulting from the high complexity of cancer treatment challenges in practice. Therefore, it is essential to engage patients, family, and caregivers in this network.

We could identify several opportunities for further research: (¹1. Ferlay J, Colombet M, Soerjomataram I, Mathers C, Parkin DM, Piñeros M, et al. Estimating the global cancer incidence and mortality in 2018: GLOBOCAN sources and methods. Int J Cancer. 2018; 144(8):1941–53. doi: 10.1002/ijc.31937
https://doi.org/10.1002/ijc.31937... ) exploring themes in the international community, such as trends with an aging population, new treatment, and expensive drugs; (²2. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018;68(6):394–424. doi: 10.3322/caac.21492
https://doi.org/10.3322/caac.21492... ) further exploring disparities in developing countries regarding cancer treatment; and (³3. World Health Organization. Global health observatory. Geneva: WHO; 2018. Available from: https://www.who.int/data/gho. Accessed 10 December 2021.
https://www.who.int/data/gho... ) collaborating with central authors in the world network.

Disclaimer.

Authors hold sole responsibility for the views expressed in the manuscript, which may not necessarily reflect the opinion or policy of the Revista Panamericana de Salud Pública / Pan American Journal of Public Health and/or those of the Pan American Health Organization.

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