Time to Surgery and Breast Cancer Survival in the United States

Association between the time to surgery and survival among patients with colon cancer: A population-based study

Factors associated with time-to-surgery (TTS) and survival in colon cancer has not been well studied. Cancer Care Ontario recommends surgery within 42 days of diagnosis and that 90% of patients meet this benchmark. We describe factors associated with TTS and survival in routine clinical practice.

METHODS

Retrospective population-based cohort study of patients receiving elective colonic resection after diagnosis of colon cancer in Ontario, Canada from 2002 to 2008 followed until 2012. Factors associated with TTS were identified using multivariate log-binomial and Quantile regression at 42 days and 90th percentiles. The association between TTS and cancer-specific (CSS) and overall survival (OS) were examined using multivariate Cox regression.

RESULTS

4326 patients; median age 71 years and 52% male. Median TTS was 24 days (IQR 14-37); at the 90th percentile 56 days. Factors associated with TTS ≥ 42 days and >90th percentile included older age, co-morbid illness, surgeon volume, and stage I disease (P < 0.05 for all). In patients whose TTS was either at 42 days or 90th percentile, those ≥80 years old waited two weeks longer than those <60 years, individuals with co-morbid illness waited 10 days longer than without co-morbidity, and patients with stage I disease waited 10 days longer than those with stage IV disease (P < 0.05 for all). Delay in TTS > 42 days or >90th percentile was not associated with OS or CSS.

CONCLUSION

Age, co-morbidity, and stage of cancer are associated with TTS. There was no association between TTS and CSS or OS.

Preoperative clinical pathway of breast cancer patients: determinants of compliance with EUSOMA quality indicators

Background:

The European Society of Breast Cancer Specialists (EUSOMA) has defined quality indicators for breast cancer (BC). The aim of this study was to describe the preoperative clinical pathway of breast cancer patients and evaluate the determinants of compliance with EUSOMA quality indicators in the Optisoins01 cohort.

Methods:

Optisoins01 is a prospective, multicentric study. Data from operable BC patients were collected, including results from before surgery to 1 year follow-up. Seven preoperative EUSOMA quality indicators were compared with the clinical pathways Optisoins01.

Results:

Six hundred and four patients were included. European Society of Breast Cancer Specialists targets were reached for indicator 1 (completeness of clinical and imaging diagnostic work-up), 3 (preoperative definitive diagnosis) and 5 (waiting time). For indicator 8 (multidisciplinary discussion), the minimum standard of 90% of the patients was reached only in general hospitals and comprehensive cancer centres. Having more than 1 medical examination within the centre was associated with an increased waiting time for surgery, whereas it was reduced by having an outpatient breast biopsy. The comprehensive cancer centre type was the only parameter associated with the other quality indicators.

Conclusions:

European Society of Breast Cancer Specialists quality indicators are a useful tool to evaluate care organisations. This study highlights the need for a standardised and coordinated preoperative clinical pathway.

Survival implications of time to surgical treatment of endometrial cancers

BACKGROUND

Optimal care for women with endometrial cancers often involves transfer of care from diagnosing physicians (eg, obstetrician-gynecologists) to treating physicians (eg, gynecologic oncologists.) It is critical to determine the effect of time to treatment on cancer outcomes to set best practices guidelines for referral processes.

OBJECTIVE

We sought to determine the impact of time from diagnosis of endometrial cancer to surgical treatment on mortality and to characterize those patients who may be at highest risk for worsened survival related to surgical timing.

STUDY DESIGN

The National Cancer Database was queried for incident endometrial cancers in adults from 2003 through 2012. Cancers were classified as low risk (grade 1 or 2 endometrioid histologies) or high risk (nonendometrioid and grade 3 endometrioid histologies) and analyzed separately. Demographic, clinicopathologic, and health system factors were collected. Unadjusted and adjusted hazard ratios for mortality were calculated by interval between diagnosis and surgery. Linear regression of patient and health care system characteristics was performed on diagnosis-to-surgery interval.

RESULTS

For low-risk cancers (N = 140,078), surgery in the first and second weeks after diagnosis was independently associated with mortality risk (hazard ratio, 1.4; 95% confidence interval, 1.3-1.5; and hazard ratio, 1.1; 95% confidence interval, 1.0-1.2, respectively). The 30-day postoperative mortality was significantly higher among patients undergoing surgery in the first or second week postdiagnosis, compared to patients treated in the third or fourth week postdiagnosis (0.7% vs 0.4%; P < .001). Mortality risk was also significantly higher than baseline when time between diagnosis and surgery was >8 weeks. Independent associations with added time to surgery of at least 1 week were seen with black race (1.1 weeks; 95% confidence interval, 0.9-1.4), uninsurance (1.3 weeks; 95% confidence interval, 1.1-1.5), Medicaid insurance (1.7 weeks; 95% confidence interval, 1.5-1.9), and Charlson-Deyo comorbidity score >1 (1.0 weeks; 95% confidence interval, 0.8-1.2). For high-risk cancers (N = 68,360), surgery in the first and second weeks after diagnosis was independently associated with mortality risk (hazard ratio, 1.5; 95% confidence interval, 1.3-1.6; and hazard ratio, 1.2; 95% confidence interval, 1.1-1.2, respectively). The 30-day postoperative mortality was significantly higher among patients undergoing surgery in the first or second week postdiagnosis, compared to patients treated in the third or fourth week postdiagnosis (2.5% vs 1.0%; P < .001). Surgery after the third week postdiagnosis was not associated with a statistically significant increase in the adjusted risk of mortality. Independent associations with added time to surgery of at least 1 week were seen with uninsurance (1.4 weeks; 95% confidence interval, 0.9-1.9) and Medicaid insurance (1.4 weeks; 95% confidence interval, 1.1-1.7).

CONCLUSION

Surgery in the first 2 weeks after diagnosis of endometrial cancer was associated with worsened survival associated with elevated perioperative mortality and treatment in low-volume hospitals. Delay in surgical treatment was a risk factor for mortality in low-risk cancers only and was likely associated with poor access to specialty care. We suggest that the target interval between diagnosis and treatment of endometrial cancers be ≤8 weeks; however, referral to an experienced surgeon and adequate preoperative optimization should be prioritized over expedited surgery.

Waiting time for cancer treatment and mental health among patients with newly diagnosed esophageal or gastric cancer: a nationwide cohort study

Background

Except for overall survival, whether or not waiting time for treatment could influences other domains of cancer patients’ overall well-being is to a large extent unknown. Therefore, we performed this study to determine the effect of waiting time for cancer treatment on the mental health of patients with esophageal or gastric cancer.

Methods

Based on the Swedish National Quality Register for Esophageal and Gastric Cancers (NREV), we followed 7,080 patients diagnosed 2006–2012 from the time of treatment decision. Waiting time for treatment was defined as the interval between diagnosis and treatment decision, and was classified into quartiles. Mental disorders were identified by either clinical diagnosis through hospital visit or prescription of psychiatric medications. For patients without any mental disorder before treatment, the association between waiting time and subsequent onset of mental disorders was assessed by hazard ratios (HRs) with 95% confidence interval (CI), derived from multivariable-adjusted Cox model. For patients with a preexisting mental disorder, we compared the rate of psychiatric care by different waiting times, allowing for repeated events.

Results

Among 4,120 patients without any preexisting mental disorder, lower risk of new onset mental disorders was noted for patients with longer waiting times, i.e. 18–29 days (HR 0.86; 95% CI 0.74-1.00) and 30–60 days (HR 0.79; 95% CI 0.67-0.93) as compared with 9–17 days. Among 2,312 patients with preexisting mental disorders, longer waiting time was associated with more frequent psychiatric hospital care during the first year after treatment (37.5% higher rate per quartile increase in waiting time; p for trend = 0.0002). However, no such association was observed beyond one year nor for the prescription of psychiatric medications.

Conclusions

These data suggest that waiting time to treatment for esophageal or gastric cancer may have different mental health consequences for patients depending on their past psychiatric vulnerabilities. Our study sheds further light on the complexity of waiting time management, and calls for a comprehensive strategy that takes into account different domains of patient well-being in addition to the overall survival.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-016-3013-7) contains supplementary material, which is available to authorized users.

The impact of immediate breast reconstruction after mastectomy on time to first adjuvant treatment in women with breast cancer in a community setting

BACKGROUND

The impact of immediate breast reconstruction on the time to first adjuvant therapy is controversial.

METHODS

Retrospective study design comparing time to first treatment in women undergoing mastectomy with and without immediate reconstruction in a community cancer center.

RESULTS

Seventy-six cases fit inclusion criteria of which 44 (58%) underwent mastectomy with immediate reconstruction. Women undergoing immediate reconstruction were younger, had more bilateral mastectomies and had fewer prior breast procedures. The median time to first adjuvant therapy was longer in the immediate reconstruction group [80.5days (36-343) versus 53.5 days (18-96), p = 0.003]. Fifteen of 44 patients had the start of adjuvant treatment over 90 days after resection, 14 of whom (93%) had immediate reconstruction versus 1 (7%) who did not (p = 0.01).

CONCLUSION

In this study immediate breast reconstruction was associated with a longer time to first adjuvant treatment, with adjuvant therapies being more likely delayed over 90 days.

Second opinions from urologists for prostate cancer: Who gets them, why, and their link to treatment

BACKGROUND

Cancer patients are encouraged to obtain second opinions before starting treatment. Little is known about men with localized prostate cancer who seek second opinions, the reasons why, and the association with treatment and quality of care.

METHODS

We surveyed men who were diagnosed with localized prostate cancer in the greater Philadelphia area from 2012 to 2014. Men were asked if they obtained a second opinion from a urologist, and the reasons why. We used multivariable logistic regression models to evaluate the relationship between second opinions and definitive prostate cancer treatment and perceived quality of care.

RESULTS

A total of 2386 men responded to the survey (adjusted response rate, 51.1%). After applying exclusion criteria, the final analytic cohort included 2365 respondents. Of these, 40% obtained second opinions, most commonly because they wanted more information about their cancer (50.8%) and wanted to be seen by the best doctor (46.3%). Overall, obtaining second opinions was not associated with definitive treatment or perceived quality of cancer care. Men who sought second opinions because they were dissatisfied with their initial urologist were less likely to receive definitive treatment (odds ratio, 0.49; 95% confidence interval, 0.32-0.73), and men who wanted more information about treatment were less likely to report excellent quality of cancer care (odds ratio, 0.70; 95% confidence interval, 0.49-0.99) compared with men who did not receive a second opinion.

CONCLUSIONS

Although a large proportion of men with localized prostate cancer obtained a second opinion, the reasons for doing so were not associated with treatment choice or perceived quality of cancer care. Future study is needed to determine when second opinions contribute to increasing the value of cancer care. Cancer 2017;123:1027-34. © 2016 American Cancer Society.

Patterns of multidisciplinary care in the management of non-metastatic invasive breast cancer in the United States Medicare patient

PURPOSE

Multidisciplinary care (MDC) in managing breast cancer is resource-intensive and growing in prevalence anecdotally, although care patterns are poorly characterized. We sought to determine MDC patterns and effects on care in the United States Medicare patient.

METHODS

Patients diagnosed with non-metastatic invasive breast cancer from 1992-2009 were reviewed using the Survival, Epidemiology, and End Results (SEER)-Medicare linked dataset. MDC was defined as a post-diagnosis, preoperative visit with a surgical, medical, and radiation oncologist. Same-day MDC (MDCSD) was the MDC subset having all three visits on one date.

RESULTS

Among 88,865 patients, MDC was utilized in 2.9 %, with 14.1 % of these having MDCSD. MDC use did not vary by stage, but MDC patients were more likely to be younger, black, receive lumpectomy, have fewer nodes examined, and receive radiotherapy. MDCSD patients were more likely than non-MDC patients to be black, receive mastectomy, and receive radiotherapy. MDC and MDCSD use increased over time and varied by geographic region, with rural patients less likely to receive MDC (OR 0.54 [95 % CI 0.45-0.65]) and MDCSD (OR 0.32 [95 % CI 0.19-0.54]). Radiotherapy after breast conserving surgery, used in 86.2 % of non-MDC patients, was administered to 90.2 % of MDC (p < 0.001) and 92.6 % of MDC(SD) (p = 0.096) patients. Post-mastectomy radiotherapy was administered in 52.0 % of non-MDC patients, 63.8 % of MDC (p = 0.050), and 89.1 % of MDC(SD) (p = 0.011) patients after propensity score adjustment.

CONCLUSION

While increasing, few Medicare patients undergo MDC and MDCSD is rare. MDC may improve quality and MDCSD should be considered for patient convenience. While not yet widespread, efforts should integrate MDC and MDCSD across the U.S.

Tumor growth rate of invasive breast cancers during wait times for surgery assessed by ultrasonography

Several studies suggest that delay in the surgical treatment of breast cancer is significantly associated with lower survival. This study evaluated the tumor growth rate (TGR) of invasive breast cancers during wait times for surgery quantitatively using ultrasonography (US) and identified clinicopathologic factors associated with TGR.This retrospective study was approved by our institutional review board and the requirement for written informed consent was waived. Between August 2013 and September 2014, a total of 323 unifocal invasive breast cancers in 323 women with serial US images at the time of diagnosis and surgery were included. Tumor diameters and volumes were measured using 2-orthogonal US images. TGR during wait times for surgery was quantified as specific growth rates (SGR; %/day) and was compared with clinicopathologic variables using univariate and multivariate analyses.Median time from diagnosis to surgery was 31 days (range, 8-78 days). Maximum tumor diameters and volumes at the time of surgery (mean, 15.6 mm and 1.6 cm) were significantly larger than at diagnosis (14.7 mm and 1.3 cm) (P < 0.001). On multivariate analysis, surrogate molecular subtype was a significant independent factor of SGR (P = 0.001); triple negative cancers showed the highest SGR (1.003%/day) followed by HER2-positive (0.859 %/day) and luminal cancers (luminal B, 0.208 %/day; luminal A, 0.175%/day) (P < 0.001). Clinical T stage was more frequently upgraded in nonluminal (triple negative, 18% [12/67]; HER2-positive, 14% [3/22]) than luminal cancers (luminal B, 3% [1/30]; luminal A, 2% [4/204]) (P < 0.001).Invasive breast cancers with aggressive molecular subtypes showed faster TGR and more frequent upgrading of clinical T stage during wait times for surgery.

Access to Care in Vermont: Factors Linked With Time to Chemotherapy for Women With Breast Cancer-A Retrospective Cohort Study

PURPOSE

In the rural United States, there are multiple potential barriers to the timely initiation of chemotherapy. The goal of this study was to identify factors associated with delays in the time from initial diagnosis to first systemic therapy (TTC) among women with breast cancer in Vermont.

METHODS

Using data from the Vermont Cancer Registry, we explored TTC for 702 female Vermont residents diagnosed with stage I to III breast cancer between 2006 and 2010 who received adjuvant chemotherapy. Multivariable linear regression was used to evaluate the associations between TTC and patient, tumor, treatment, and geographic variables.

RESULTS

Mean TTC was 10.2 weeks. Longer drive time (P < .001), more invasive surgery (P = .01), and breast reconstruction (P < .001) were each associated with longer TTC. Each additional 15 minutes of drive time was associated with a 0.34-week (95% CI, 0.22 to 0.46 weeks) increase in TTC. Participants age younger than 65 years whose primary payer was Medicare (n = 27) had significantly longer average TTC, by 2.37 weeks (P = .001), compared with those with private or military insurance. There was also substantial variation in TTC across hospitals (P < .001).

CONCLUSION

Most female patients with stage I to III breast cancer in Vermont are receiving adjuvant chemotherapy within the National Comprehensive Cancer Network-recommended timeframe; however, improvements remain needed for certain subgroups. Novel approaches for women with long drive times need to be developed and evaluated in the community. Variation in TTC by hospital, even after adjusting for patient, tumor, and treatment factors, also suggests opportunities for process improvement.

Elevated expression of chemokine C-C ligand 2 in stroma is associated with recurrent basal-like breast cancers

Despite advances in treatment, up to 30% of breast cancer patients experience disease recurrence accompanied by more aggressive disease and poorer prognosis. Treatment of breast cancer is complicated by the presence of multiple breast cancer subtypes, including: luminal, Her2 overexpressing, and aggressive basal-like breast cancers. Identifying new biomarkers specific to breast cancer subtypes could enhance the prediction of patient prognosis and contribute to improved treatment strategies. The microenvironment influences breast cancer progression through expression of growth factors, angiogenic factors and other soluble proteins. In particular, chemokine C-C ligand 2 (CCL2) regulates macrophage recruitment to primary tumors and signals to cancer cells to promote breast tumor progression. Here we employed a software-based approach to evaluate the prognostic significance of CCL2 protein expression in breast cancer subtypes in relation to its expression in the epithelium or stroma or in relation to fibroblast-specific protein 1 (Fsp1), a mesenchymal marker. Immunohistochemistry analysis of tissue microarrays revealed that CCL2 significantly correlated with Fsp1 expression in the stroma and tumor epithelium of invasive ductal carcinoma. In the overall cohort of invasive ductal carcinomas (n=427), CCL2 and Fsp1 expression in whole tissues, stroma and epithelium were inversely associated with cancer stage and tumor size. When factoring in molecular subtype, stromal CCL2 was observed to be most highly expressed in basal-like breast cancers. By Cox regression modeling, stromal CCL2, but not epithelial CCL2, expression was significantly associated with decreased recurrence-free survival. Furthermore, stromal CCL2 (HR=7.51 P=0.007) was associated with a greater hazard than cancer stage (HR=2.45, P=0.048) in multivariate analysis. These studies indicate that stromal CCL2 is associated with decreased recurrence-free survival in patients with basal-like breast cancer, with important implications on the use of stromal markers for predicting patient prognosis.

Effects of state-level medicaid policies and patient characteristics on time to breast cancer surgery among medicaid beneficiaries

Medicaid beneficiaries with cancer are less likely to receive timely and high-quality care. This study examined whether differences in state-level Medicaid policies affect delays in time to surgery (TTS) among women diagnosed with breast cancer. Using 2006-2008 Medicaid data, we identified women aged 18-64 enrolled in Medicaid diagnosed with breast cancer. Analyses examined associations of state-specific Medicaid surgery reimbursements, Medicaid eligibility recertification period (annually vs. shorter) and required patient copayment on time from breast cancer diagnosis to receipt of breast surgery. Patients receiving neoadjuvant therapy were excluded. Separate multivariable regression analyses controlling for patient demographic characteristics and clustering by state were performed for breast conserving surgery (BCS), inpatient mastectomy, and outpatient mastectomy. The study included 7542 Medicaid beneficiaries with breast cancer: 3272 received BCS, 2156 outpatient mastectomy, and 2115 inpatient mastectomy. Higher Medicaid reimbursements for BCS were associated with decreased time from diagnosis to surgery. A 12-month (vs. <12 month) Medicaid eligibility recertification period was associated with decreased TTS for BCS and outpatient mastectomy. Black Medicaid beneficiaries (compared with non-Hispanic White beneficiaries) were more likely to experience delays for all three types of surgery, while Hispanic beneficiaries were more likely to experience delays only for outpatient mastectomy. State-level Medicaid policies and patient characteristics can affect receipt of timely surgery among Medicaid beneficiaries with breast cancer. As delays in surgery can increase morbidity and mortality, changes to state Medicaid policies and health system programs are needed to improve access to care for this vulnerable population.

Imaging in the evaluation and follow-up of early and advanced breast cancer: When, why, and how often?

Imaging in the evaluation and follow-up of patients with early or advanced breast cancer is an important aspect of cancer care. The role of imaging in breast cancer depends on the goal and should only be performed to guide clinical decisions. Imaging is valuable if a finding will change the course of treatment and improve outcomes, whether this is disease-free survival, overall survival or quality-of-life. In the last decade, imaging is often overused in oncology and contributes to rising healthcare costs. In this context, we review the data that supports the appropriate use of imaging for breast cancer patients. We will discuss: 1) the optimal use of staging imaging in both early (Stage 0-II) and locally advanced (Stage III) breast cancer, 2) the role of surveillance imaging to detect recurrent disease in Stage 0-III breast cancer and 3) how patients with metastatic breast cancer should be followed with advanced imaging.

Racial disparities in all-cause mortality among younger commercially insured women with incident metastatic breast cancer

Racial disparities in breast cancer mortality persist and are likely related to multiple factors. Over the past decade, progress has been made in treating metastatic breast cancer, particularly in younger women. Whether disparities exist in this population is unknown. Using administrative claims data between 2000 and 2011 (OptumInsight, Eden Prairie, MN) of members insured through a large national US health insurer, we identified women aged 25-64 years diagnosed with incident metastatic breast cancer diagnosed between November 1, 2000, and December 31, 2008. We examined time from diagnosis to death, with up to 3 years of follow-up. We stratified analyses by geocoded race and socio-economic status, age-at-diagnosis, morbidity score, US region of residence, urban/non-urban, and years of diagnosis. We constructed Kaplan-Meier survival plots and analyzed all-cause mortality using multivariate Cox proportional hazard models. Among 6694 women with incident metastatic breast cancer (78 % Caucasian, 4 % African American, and 18 % other), we found higher mortality rates among women residing in predominantly African American versus Caucasian neighborhoods (hazard ratio (HR) 1.84; 95 % confidence interval, CI 1.39-2.45), women with high versus lower morbidity (HR 1.30 [1.12-1.51]), and women whose incident metastatic diagnosis was during 2000-2004 versus 2005-2008 (HR 1.60 [1.39-1.83]). Caucasian (HR 0.61 [0.52-0.71]) but not African American women (HR not significant) experienced improved mortality in 2005-2008 versus 2000-2004. Despite insured status, African American women and women with multi-morbidity had poorer survival. Only Caucasian women had improved mortality over time. Modifiable risk factors for increased mortality need to be addressed in order to reduce disparities.