PHILADELPHIA (March 28, 2019) — More than 36 percent of breast cancer patients transfer their care to new providers, incurring the risk that surgery and other treatments will be delayed, increasing the likelihood that recommendations for timely treatment will not be adhered to, according to a recent study by Fox Chase Cancer Center researchers.
Among 622,793 patients diagnosed with non-metastatic breast cancer, 36.6 percent of patients transferred care, adding on average 7.3 days prior to surgery, 7.8 days before starting chemotherapy, 8.7 days before radiotherapy, and 9.8 days for endocrine therapy, says the report, which appears in the journal Breast Cancer Research and Treatment. Delays can impact long-term survival rates. Study can be found here: https://link.springer.com/article/10.1007/s10549-018-5046-x
Richard J. Bleicher, MD, FACS, leader of the Breast Cancer Program at Fox Chase, and Lori J. Goldstein, MD, FASCO, director of the Naomi and Phil Lippincott Breast Evaluation Center at Fox Chase, co-authored the study.
“Recent analyses of large national datasets show that not only do delays impact overall and disease-specific survival, but waiting times between presentation and breast surgery in the United States are increasing,” Bleicher and Goldstein wrote. “Unfortunately, in early stage breast cancer there is a relative 9–10 percent drop in overall survival for every month of delay, and a relative 26 percent decline in disease-specific survival for every two months of delay between diagnosis and surgery. Our goal here was to determine how much transfers of care before surgery delay breast cancer care, and how frequency such transfers between providers occurred nationally.”
The researchers analyzed data from the National Cancer Database (NCDB), a joint program of the Commission on Cancer (CoC) of the American College of Surgeons and the American Cancer Society. It is a nationwide database of oncology outcomes for more than 1,500 CoC-accredited cancer programs in the United States and Puerto Rico. Some 70 percent of all newly diagnosed cases of cancer in the United States are reported to the NCDB.
Currently there are no time-based quality standards related to when surgery should occur. However, when surgery is delayed, it effects subsequent interventions, compromising the timing of systemic and radiation therapies, which do have time-based quality standards. In addition, the data showed that a transfer of care also increased the odds that patients wouldn’t end up treated within the time frames recommended for chemotherapy (65.4 percent), radiotherapy (25.6 percent), and endocrine therapy (56.5 percent).
Although delays are detrimental, Bleicher and Goldstein noted that they do not recommend prohibiting or discouraging second opinions or transfers of care for breast cancer patients. The increase in transfers of care by 10 percent over the 11 years of study demonstrates that second opinions may be valuable and are felt to be useful to patients. Instead, however, they recommended that institutions periodically assess their patterns of referral and consider ways to expedite patients whose time from diagnosis has been lengthy, such as for those who transfer care.
“Patients should also be aware that delays matter, and while second opinions may be valuable, obtaining too many additional opinions beyond that may cause unnecessary delays that impact their outcome,” Bleicher said.