Time from Diagnosis to Surgical Treatment of Breast Cancer: Factors Influencing Delays in Initiating Treatment

No clear guidelines exist defining the appropriate time frame from diagnosis to definitive surgical treatment of breast cancer. Studies have suggested that treatment delays greater than 90 days may be associated with stage migration. We sought to evaluate demographic factors that influence 30-day and 90-day benchmarks for time from diagnosis to definitive surgical treatment of breast cancer. Between 2004 and 2007, 19,896 women with stage I to III invasive breast cancer were treated with primary surgical therapy and did not receive preoperative systemic therapy in the California Cancer Registry. Overall, 75.7 per cent of patients were treated within 30 days of diagnosis, and 95.5 per cent of patients were treated within 90 days of diagnosis. Multivariate analyses revealed that treatment delays were associated with smaller tumor size, use of total mastectomy, lower socioeconomic status, and Hispanic and nonHispanic black race/ethnicity. Furthermore, disparities in those that did not meet 30-day benchmark timeframes were exaggerated with 90-day treatment delays. These benchmarks can be used to measure disparities in health care delivery.

The Use of Pelvic Radiation in Stage II Rectal Cancer: A Population-Based Analysis

National Institutes of Health (NIH) guidelines recommend the use of pelvic radiation in T3N0 rectal cancer. We sought to determine the rate of compliance with NIH radiation guidelines for patients with T3N0 rectal cancer. We performed a retrospective cohort study of T3N0 rectal cancer diagnosed between January 1, 1994, and December 31, 2003, in Region 5 of the California Cancer Registry (R5 CCR). Three hundred twenty-nine patients with T3N0 rectal cancer were identified. The mean age of the study population was 68 years (range, 28 to 93 years). Only 54.1 per cent of patients with T3N0 cancer received pelvic radiation. There was no difference in gender ( P = 0.13) or the number of nodes examined ( P = 0.19) between patients who had treatment with pelvic radiation and those who did not. However, patients receiving radiation were significantly younger (mean 64 years with radiation therapy [XRT] vs 72 years without XRT, P < 0.001) and significantly more likely to be treated with systemic chemotherapy (75% with XRT vs 8.6% without XRT, P < 0.001). Significant numbers of patients with T3N0 rectal cancer are not receiving pelvic radiation in R5 CRR. NIH guidelines are not being translated into clinical practice. The reasons for this warrant continued investigation.

Time from diagnosis to surgical treatment of breast cancer: factors influencing delays in initiating treatment

No clear guidelines exist defining the appropriate time frame from diagnosis to definitive surgical treatment of breast cancer. Studies have suggested that treatment delays greater than 90 days may be associated with stage migration. We sought to evaluate demographic factors that influence 30-day and 90-day benchmarks for time from diagnosis to definitive surgical treatment of breast cancer. Between 2004 and 2007, 19,896 women with stage I to III invasive breast cancer were treated with primary surgical therapy and did not receive preoperative systemic therapy in the California Cancer Registry. Overall, 75.7 per cent of patients were treated within 30 days of diagnosis, and 95.5 per cent of patients were treated within 90 days of diagnosis. Multivariate analyses revealed that treatment delays were associated with smaller tumor size, use of total mastectomy, lower socioeconomic status, and Hispanic and nonHispanic black race/ethnicity. Furthermore, disparities in those that did not meet 30-day benchmark timeframes were exaggerated with 90-day treatment delays. These benchmarks can be used to measure disparities in health care delivery.

Accuracy and Upgrade Rates of Percutaneous Breast Biopsy: The Surgeon's Role

We sought to evaluate the impact of needle core size and number of core samples on diagnostic accuracy and upgrade rates for image-guided core needle biopsies of the breast. A total of 234 patients underwent image-guided percutaneous needle biopsies and subsequent surgical excision. Large-core needles (9 gauge or less) were used in 14.5 per cent of cases and the remainder were performed with smaller core needles. More than four core samples were taken in 78.9 per cent of patients. In 71.8 per cent of cases, needle biopsy pathology matched surgical excision pathology. After surgical excision, upgraded pathology was revealed in 10.7 per cent of cases. Of 11 patients (52.4%) with benign needle core pathology who had upgraded final pathology on surgical excision, 10 had a Breast Imaging Recording and Data System score 4 or 5 imaging study. Lesions smaller than 10 mm were more likely to be misdiagnosed ( P = 0.01) or have upgraded pathology ( P = 0.009). Other predictors of upgraded pathology were patient age 50 years or older ( P = 0.03) and taking four or fewer core samples ( P = 0.003). Needle core size did not impact accuracy or upgrade rates. Surgeons should exercise caution when interpreting needle biopsy results with older patients, smaller lesions, and limited sampling. Discordant pathology and imaging still mandate surgical confirmation.

The use of pelvic radiation in stage II rectal cancer: a population-based analysis

National Institutes of Health (NIH) guidelines recommend the use of pelvic radiation in T3N0 rectal cancer. We sought to determine the rate of compliance with NIH radiation guidelines for patients with T3N0 rectal cancer. We performed a retrospective cohort study of T3NO rectal cancer diagnosed between January 1, 1994, and December 31, 2003, in Region 5 of the California Cancer Registry (R5 CCR). Three hundred twenty-nine patients with T3N0 rectal cancer were identified. The mean age of the study population was 68 years (range, 28 to 93 years). Only 54.1 per cent of patients with T3N0 cancer received pelvic radiation. There was no difference in gender (P = 0.13) or the number of nodes examined (P = 0.19) between patients who had treatment with pelvic radiation and those who did not. However, patients receiving radiation were significantly younger (mean 64 years with radiation therapy [XRT] vs. 72 years without XRT, P < 0.001) and significantly more likely to be treated with systemic chemotherapy (75% with XRT vs. 8.6% without XRT, P < 0.001). Significant numbers of patients with T3N0 rectal cancer are not receiving pelvic radiation in R5 CRR. NIH guidelines are not being translated into clinical practice. The reasons for this warrant continued investigation.

Accuracy and upgrade rates of percutaneous breast biopsy: the surgeon's role

We sought to evaluate the impact of needle core size and number of core samples on diagnostic accuracy and upgrade rates for image-guided core needle biopsies of the breast. A total of 234 patients underwent image-guided percutaneous needle biopsies and subsequent surgical excision. Large-core needles (9 gauge or less) were used in 14.5 per cent of cases and the remainder were performed with smaller core needles. More than four core samples were taken in 78.9 per cent of patients. In 71.8 per cent of cases, needle biopsy pathology matched surgical excision pathology. After surgical excision, upgraded pathology was revealed in 10.7 per cent of cases. Of 11 patients (52.4%) with benign needle core pathology who had upgraded final pathology on surgical excision, 10 had a Breast Imaging Recording and Data System score 4 or 5 imaging study. Lesions smaller than 10 mm were more likely to be misdiagnosed (P = 0.01) or have upgraded pathology (P = 0.009). Other predictors of upgraded pathology were patient age 50 years or older (P = 0.03) and taking four or fewer core samples (P = 0.003). Needle core size did not impact accuracy or upgrade rates. Surgeons should exercise caution when interpreting needle biopsy results with older patients, smaller lesions, and limited sampling. Discordant pathology and imaging still mandate surgical confirmation.

The Impact of Multidisciplinary Therapy in Node-Positive Rectal Cancer

Multidisciplinary therapy (MDT) of node-positive rectal cancer is considered optimal. We performed a retrospective cohort study of node positive rectal cancer patients diagnosed between January 1, 1994 and December 31, 2003 in Region 5 of the California Cancer Registry to determine the impact of MDT on disease specific survival (DSS). During the study period, 398 patients with stage III rectal cancer were identified. Only 251 patients (63.1%) received radiation (XRT). Patients receiving XRT had significantly improved survival when compared with those who did not (5 year DSS 55% with XRT vs 36% without XRT, median follow-up 43 months, P < 0.001). There was no statistically significant difference in T stage ( P = 0.41), the number of N1 patients ( P = 0.45), or the number of positive nodes harvested (mean 11.5 w/o XRT vs 12.8 w/XRT, P = 0.37) between patients receiving XRT and those who did not. Patients receiving XRT were far more likely to receive systemic chemotherapy (83% vs 27%, P < 0.0001). Multidisciplinary therapy of node-positive rectal cancer is associated with improved DSS. However, substantial numbers of node positive rectal cancer patients are not receiving MDT. Greater efforts are needed to implement consistent multidisciplinary algorithms into rectal cancer management.

The impact of multidisciplinary therapy in node-positive rectal cancer

Multidisciplinary therapy (MDT) of node-positive rectal cancer is considered optimal. We performed a retrospective cohort study of node positive rectal cancer patients diagnosed between January 1, 1994 and December 31, 2003 in Region 5 of the California Cancer Registry to determine the impact of MDT on disease specific survival (DSS). During the study period, 398 patients with stage III rectal cancer were identified. Only 251 patients (63.1%) received radiation (XRT). Patients receiving XRT had significantly improved survival when compared with those who did not (5 year DSS 55% with XRT vs. 36% without XRT, median follow-up 43 months, P < 0.001). There was no statistically significant difference in Tstage (P = 0.41), the number of N1 patients (P = 0.45), or the number of positive nodes harvested (mean 11.5 w/o XRT vs. 12.8 w/XRT, P = 0.37) between patients receiving XRT and those who did not. Patients receiving XRT were far more likely to receive systemic chemotherapy (83% vs. 27%, P < 0.0001). Multidisciplinary therapy of node-positive rectal cancer is associated with improved DSS. However, substantial numbers of node positive rectal cancer patients are not receiving MDT. Greater efforts are needed to implement consistent multidisciplinary algorithms into rectal cancer management.

The Impact of the Ratio of Positive to Total Lymph Nodes Examined and Outcome in Colorectal Cancer

We sought to examine the significance of the number of nodes examined in node-positive colorectal cancer. Between January 1, 1994, and December 31, 2003, 7192 patients with colorectal cancer underwent potentially curative resection in Region 5 of the California Cancer Registry. Of these patients, 2636 patients were node-positive: 65.1 per cent were N1 and 34.9 per cent were N2. The median follow up was 39.5 months. The mean number of nodes examined was 10.4 (range, 1-89) for NO, 11.0 (range, 1-72) for N1, and 14.6 (range, 4-79) for N2 ( P < 0.0001). N1 and N2 patients were stratified according to the percentage of positive nodes into quintiles (0.19 or less, 0.20 to 0.39, 0.40 to 0.59, 0.60 to 0.79, and 0.80 to 1.0). In both N1 and N2 disease, a lower percentage of lymph nodes involved with metastatic disease was associated with improved survival ( P < 0.0001). The increasing ratio of positive to total nodes was the result of a decrease in the total number of nodes examined in N1 disease and a steeper decline in total nodes examined in relation to the increase in the number of positive nodes in N2 disease. The ratio of positive to total nodes has prognostic significance in node-positive colorectal cancer.

Disparities in the Surgical Management of Women with Stage I Breast Cancer

We sought to evaluate factors influencing the choice of surgery for women with early-stage breast cancer. Between 1996 and 2005, 47,837 women who were diagnosed with Stage I breast cancer underwent partial (PM) or total mastectomy (TM) in the California Cancer Registry. A total of 72.8 per cent of women underwent PM. Those treated in the most recent 5-year period were more likely to undergo PM than in the prior 5 years (76.5 vs 69.5%, P < 0.0001). PM rates increased with increasing socioeconomic status (SES): 65.1 per cent of patients in the lowest SES quintile underwent PM versus 77.2 per cent in the highest SES quintile ( P < 0.0001). Forty- to 64-year-old women were more likely to receive PM compared with their older and younger counterparts (74.5 vs 71.2 and 67.0%, respectively; P < 0.0001). Asian/Pacific Islander women were least likely to undergo PM (64.0%), whereas non-Hispanic black women were most likely to undergo PM (75.0%) ( P < 0.0001). On multivariate analysis, these demographic factors remained independent predictors of surgical treatment. PM rates have increased over time; however, significant differences in surgical management exist among women of different race/ethnic groups, ages, and SES. Further research is required to elucidate modifiable factors that impact the choice of surgery for women with early-stage breast cancer.

The impact of the ratio of positive to total lymph nodes examined and outcome in colorectal cancer

We sought to examine the significance of the number of nodes examined in node-positive colorectal cancer. Between January 1, 1994, and December 31, 2003, 7192 patients with colorectal cancer underwent potentially curative resection in Region 5 of the California Cancer Registry. Of these patients, 2636 patients were node-positive: 65.1 per cent were N1 and 34.9 per cent were N2. The median follow up was 39.5 months. The mean number of nodes examined was 10.4 (range, 1-89) for N0, 11.0 (range, 1-72) for N1, and 14.6 (range, 4-79) for N2 (P < 0.0001). N1 and N2 patients were stratified according to the percentage of positive nodes into quintiles (0.19 or less, 0.20 to 0.39, 0.40 to 0.59, 0.60 to 0.79, and 0.80 to 1.0). In both N1 and N2 disease, a lower percentage of lymph nodes involved with metastatic disease was associated with improved survival (P < 0.0001). The increasing ratio of positive to total nodes was the result of a decrease in the total number of nodes examined in N1 disease and a steeper decline in total nodes examined in relation to the increase in the number of positive nodes in N2 disease. The ratio of positive to total nodes has prognostic significance in node-positive colorectal cancer.

Disparities in the surgical management of women with stage I breast cancer

We sought to evaluate factors influencing the choice of surgery for women with early-stage breast cancer. Between 1996 and 2005, 47,837 women who were diagnosed with Stage I breast cancer underwent partial (PM) or total mastectomy (TM) in the California Cancer Registry. A total of 72.8 per cent of women underwent PM. Those treated in the most recent 5-year period were more likely to undergo PM than in the prior 5 years (76.5 vs 69.5%, P < 0.0001). PM rates increased with increasing socioeconomic status (SES): 65.1 per cent of patients in the lowest SES quintile underwent PM versus 77.2 per cent in the highest SES quintile (P < 0.0001). Forty- to 64-year-old women were more likely to receive PM compared with their older and younger counterparts (74.5 vs 71.2 and 67.0%, respectively; P < 0.0001). Asian/Pacific Islander women were least likely to undergo PM (64.0%), whereas non-Hispanic black women were most likely to undergo PM (75.0%) (P < 0.0001). On multivariate analysis, these demographic factors remained independent predictors of surgical treatment. PM rates have increased over time; however, significant differences in surgical management exist among women of different race/ethnic groups, ages, and SES. Further research is required to elucidate modifiable factors that impact the choice of surgery for women with early-stage breast cancer.

The impact of young age on outcome in colon cancer

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Background: The early age of diagnosis (<40 years) of colon cancer (CC) is generally considered to be associated with a particularly grave prognosis. Our objective was to determine the prognostic relevance of young age on outcome in CC. Methods: Retrospective cohort study from Region 5 of the California Cancer Registry (R5 CCR). Survival by Kaplan- Meier with significance assessed by log-rank test, T-test and Chi Square where appropriate. Results: Between January 1,1994 and December 31, 2003 10,730 patients with CC were diagnosed in R5 CCR. The patients ranged in age from 18–103 years (mean 71.1 years). Two hundred fourteen patients (2%) were 40 years of age or younger. The mean age of young patients was 34.6 years (range 18–40) and for old patients 71.3 years (range 41–103). The mean number of nodes examined were 18.5 in the young CC patient and 18.4 in the remainder of CC patients. There was no significant difference in the anatomic sub-site of the primary between younger and older CC patients (p=0.43). Young patients presented with more advanced primary tumors (T4 18.7% vs. 11.6%, p=0.03), more frequently with more extensive nodal involvement (N+ (54.4% vs. 40.2%, p<0.0001), and more frequently with distant metastatic disease (M1 25.7% vs. 18.3%, p=0.005). Despite these adverse characteristics, young patients had a significantly better disease specific survival (DSS) compared to their older counterparts (5 year survival 70.1% vs. 62.3%, p=0.02). Young patients had a suggestion of improved DSS compared to older patients in Stage I disease (5 yr DSS 96.0% vs. 90.5%, p=0.34) with more certain evidence of improved DSS in Stage II (5 yr DSS 94.8% vs. 79.9%, p=0.02), Stage III (5 yr DSS 73.4% vs. 57.2%, p=0.01) and most profoundly in Stage IV (5 yr DSS 20.1% vs. 0.08%, p=0.002). Conclusions: Despite adverse characteristics at diagnosis, young CC patients have a better DSS than their older counterparts. This is in contrast to the generally held opinion that young CC patients fare worse. This may reflect the ability of young CC patients to accept and tolerate more intense and aggressive therapies.

No significant financial relationships to disclose.

The impact of hospital volume on the number of nodes retrieved and outcome in colorectal cancer

We sought to examine the impact of hospital surgical volume on the number of nodes harvested and survival in colorectal cancer (CRC). Between January 1994 and December 2004, a total of 8567 patients with T1, 2, 3, and 4 primary tumors and N0, N1, or N2 disease were studied. Hospitals were stratified into very low volume (VLV) (<33 cases/year), low volume (LV) (33-56 cases/year), and medium volume (MV) (57-84 cases/year). Surgery for CRC was performed most commonly at VLV hospitals: 3488 (40.7%) VLV centers versus 2359 (27.5%) LV centers versus 2720 (31.7%) MV centers. The mean number of nodes retrieved for VLV centers was 8.6, for LV centers 9.4, and MV centers 10.2 (P < 0.0002). Actuarial 5-year survival for VLV centers was 71.4 per cent, for LV centers 75.6 per cent, and for MV 77.0 per cent (P < 0.00001). By Cox proportional hazards analysis, hospital volumes (P < 0.0011) and the number of lymph nodes harvested (P < 0.0034) remain significant predictors of disease specific survival. The number of nodes retrieved is impacted by hospital volumes. Hospital volumes impact survival in CRC. These findings cannot be attributed solely to improved staging due to increased node retrieval in VLV, LV, and MV hospitals.

The Impact of Hospital Volume on the Number of Nodes Retrieved and Outcome in Colorectal Cancer

We sought to examine the impact of hospital surgical volume on the number of nodes harvested and survival in colorectal cancer (CRC). Between January 1994 and December 2004, a total of 8567 patients with T1, 2, 3, and 4 primary tumors and N0, N1, or N2 disease were studied. Hospitals were stratified into very low volume (VLV) (<33 cases/year), low volume (LV) (33–56 cases/year), and medium volume (MV) (57–84 cases/year). Surgery for CRC was performed most commonly at VLV hospitals: 3488 (40.7%) VLV centers versus 2359 (27.5%) LV centers versus 2720 (31.7%) MV centers. The mean number of nodes retrieved for VLV centers was 8.6, for LV centers 9.4, and MV centers 10.2 (P < 0.0002). Actuarial 5-year survival for VLV centers was 71.4 per cent, for LV centers 75.6 per cent, and for MV 77.0 per cent (P < 0.00001). By Cox proportional hazards analysis, hospital volumes (P < 0.0011) and the number of lymph nodes harvested (P < 0.0034) remain significant predictors of disease specific survival. The number of nodes retrieved is impacted by hospital volumes. Hospital volumes impact survival in CRC. These findings cannot be attributed solely to improved staging due to increased node retrieval in VLV, LV, and MV hospitals.