Grappling with cancer’s time toxicity challenge

How much time do cancer patients spend in healthcare settings, and how can we decrease it?

By Andrew Hertler, MD, FACP

When a patient has incurable metastatic cancer, time is exceedingly valuable. The concept of the “time toxicity” of cancer treatment has gained increasing attention in recent years, due to growing concerns about the number of days that patients spend in healthcare settings, rather than at home. Last week in JAMA Network Open, a team of researchers shed light on the extent of the issue, in one of the most robust studies on the topic to date. It’s a wake-up call to the field.

In the first year after diagnosis for metastatic cancer, the average Medicare beneficiary had 40 days (prostate cancer) to 63 days (colorectal) with some form of healthcare interaction outside the home. The percentage of contact days was much higher for those patients who did not survive the first year. 

The number of contact days also increased over the study period — 2008 through 2019 — likely due to the large number of novel, more complex treatment plans. Breast cancer saw the largest growth over that time, from 45 to 58 contact days. 

Of course, many of these contact days, for purposes such as outpatient treatments, diagnostic tests, and hospitalizations, are essential and life-extending. Yet, the study’s findings raise important questions. If someone with incurable colorectal cancer knew early on that with a proposed treatment regimen they might spend 9 weeks of the following year in healthcare visits — not to mention all the calls, logistics and travel that surround those touchpoints — would that change their treatment preferences? If nothing else, patients should have an idea of what to expect and if there are any options that might help them spend more of their precious time at home.

Next, how can we in the oncology community reduce contact days without compromising outcomes? Several strategies come to mind.

• Care navigation. An effective care navigation program may help reduce unnecessary contact days in different ways. For example, navigators can coordinate appointments so patients can get multiple services on the same day, rather than spread them out over several days. They can also help patients manage their side effects and symptoms at home, when appropriate, to avoid unplanned ED visits and hospitalizations.  
• Shortened courses of radiation therapy. Called hypofractionation, this approach delivers a course of radiation therapy over fewer days than conventional therapy. In some cases, patients can avoid weeks of outpatient visits. While professional societies endorse these shortened courses in specific scenarios and they are broadly adopted outside the U.S., adoption has been more variable here.
• Home therapy. With the advent of effective therapy which can be administered at home — examples include Herceptin Hylecta, Opdivo Qvantig, Tecentriq Hybreza, and Keytruda QLEX, as well as oral medications — patients can decrease the number of outpatient visits.
• Judicious treatment selection for frail patients. Cancer patients with cachexia — loss of muscle mass — and frailty syndrome have worse clinical outcomes from aggressive anticancer treatments. They are also less likely to tolerate treatments, putting them at risk for avoidable hospitalizations and ED visits near the end of life. Screening for these conditions can help identify patients for whom aggressive treatments may do more harm than good.  

Of note, the data used for the study ends in 2019, before the surge of telemedicine use that came with the coronavirus pandemic. Logically, it may be tempting to think that telemedicine might simply replace in-person visits, resulting in fewer contact days. Yet so far, we’re still waiting for more data on the impacts. One recent study of stage IV cancer patients found that while telemedicine visits increased and ambulatory visits decreased early in the pandemic, ED visits and hospitalizations went up, as did overall contact days.

Given growing concerns about time toxicity in oncology, I look forward to more studies measuring the phenomenon. As our knowledge base deepens and we look for ways to make treatment less time-toxic, we need to take a nuanced approach. It’s not just about the absolute number of days that patients spend in healthcare settings or counting all settings as equal (a day in the ICU is much more taxing than one when you get a diagnostic test). It’s about making sure that every visit, every treatment, and every interaction is working to achieve the best possible outcomes, is consistent with the patient’s goals and preferences, and doesn’t require more trips from home than necessary.  

About the Author

Dr. Andrew Hertler became Evolent’s chief medical officer emeritus and senior advisor in January 2025, following more than a decade as CMO. A board-certified oncologist with 29 years of experience in clinical practice, he is currently focused on advancing innovation for Evolent's oncology management solution.

Dr. Hertler is a nationally recognized leader in oncology clinical practice and value-based cancer care. He has volunteered on a number of American Society of Clinical Oncology committees, including the Clinical Practice, Quality of Care and Payment Reform Committees, as well as the Quality Oncology Practice Initiative Certification Program Oversight Council. 

Learn more about Dr. Hertler.