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Surgical delays worsen breast cancer outcomes
Longer time to surgery appeared associated with lower OS and disease-specific survival rates among women with breast cancer, according to the results of two population-based studies.
Additionally, reduced time to surgery (TTS) appeared to confer benefits comparable to certain standard therapies, the researchers reported.
Richard J. Bleicher
“Nearly every patient who walks through the door asks, out of concern, how soon they will need to schedule surgery or how much time they have before starting treatment,” Richard J. Bleicher, MD, associate professor of surgical oncology and director of the breast fellowship program at Fox Chase Cancer Center, told HemOnc Today. “Other patients ask if they have the time for multiple opinions. The problem has been that there have been no clear data on the effect of an increasing time between diagnosis and surgery for us to answer this question for patients.”
Controversy surrounds the connection between TTS and effects on breast cancer survival, according to study background. Some clinicians have sought to include TTS as a breast cancer quality measure.
Thus, Bleicher and colleagues sought to determine if TTS — defined as time from diagnosis to surgery — correlated with OS and disease-specific survival (DSS) for women with breast cancer.
To do so, the researchers conducted two independent population-based studies using national data collected from the SEER-Medicare–linked database and the National Cancer Database.
The former cohort included patients aged older than 65 years, whereas the latter cohort included women treated at Commission on Cancer–accredited centers throughout the U.S.
Bleicher and colleagues evaluated OS as a function of time between diagnosis and surgery at five intervals (≤ 30 days, 31-60 days, 61-90 days, 91-120 days and 121-180 days), as well as DSS survival at 60-day intervals.
All patients included in the study received a diagnosis of noninflammatory, nonmetastatic invasive breast cancer, with surgery prescribed as initial treatment.
The SEER-Medicare study included data from a cohort of 94,544 patients (mean age, 75.2±6.2 years) diagnosed with breast cancer between 1992 and 2009.
The researchers observed that with each interval of delay increase, the overall rate of OS decreased (HR = 1.09; 95% CI, 1.06-1.13). The OS rate further decreased for patients with stage I (HR = 1.13; 95% CI, 1.08-1.18) and stage II disease (HR = 1.06; 95% CI, 1.01-1.11).
Disease-specific mortality increased with each 60-day interval in this cohort (subdistribution HR [sHR] = 1.26; 95% CI, 1.02-1.54), with a significant association for patients with stage I disease (sHR = 1.84; 95% CI, 1.1-3.07).
The National Cancer Database cohort included data from 115,790 patients (mean age, 60.3±13.4 years) diagnosed between 2003 and 2005.
The overall mortality HR was 1.1 (95% CI; 1.07-1.13) for each increasing TTS interval. After adjustment for demographic, tumor and treatment factors, the association remained significant for patients with stage I (HR = 1.16; 95% CI, 1.12-1.21) and stage II disease (HR = 1.09; 95% CI, 1.05-1.13).
“We were surprised by how remarkably consistent the results were,” Bleicher said in an interview. “The consistency between the two analyses suggests to us that the findings are real for the population as a whole, and not something that is tied to a particular subset of the U.S. breast cancer population.”
The researchers noted that, due to ethical concerns regarding delays in treatment, a randomized controlled trial studying the correlation between TTS and breast cancer outcomes is unlikely.
“Shortening delays wherever possible is a no-brainer in terms of improving patient outcomes,” Bleicher said. “It comes without the costs or side effects of most interventions we do to improve survival. These findings are also critical information for surgeons to know, so that they can clearly and properly answer those questions frequently posed by patients about the effect of a delay in surgery on their outcome. Now we can advise patients about the down side of getting that third opinion, or taking, for example, a 3-week vacation before starting treatment.” – by Cameron Kelsall
For more information:
Richard J. Bleicher, MD, can be reached at richard.bleicher@fccc.edu.
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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“Doctor, how soon should this be done?” This is a question that every breast cancer surgeon has heard at some point. Some patients want their surgery done as soon as they receive the diagnosis; others may have travel plans, or feel the need to see other consultants. Until now, we have had little actual data to inform our reply to this question.
In this study, Bleicher and colleagues evaluate two separate datasets — SEER–Medicare for patients aged older than 65 years, and the National Cancer Data Base for younger adult patients. In both, they found that shorter time to surgery was associated with better OS, particularly in patients with early-stage breast cancer.
To be clear, the study did not define the “optimal time to surgery,” but rather, compared those who had surgery within 30 days from diagnosis (an arbitrary cutoff) to those who had surgery within 31-60 days and 61-90 days. Although the researchers found that for each incremental 30-day time interval, the HR for OS was 1.1, it is unlikely that those who have surgery 31 days after diagnosis have an OS estimate that is 10% less than those who have surgery at 29 days. Still, when considering the data in a broader context, it makes intuitive sense that resecting disease earlier leads to better prognosis than those whose treatment is delayed.
What remains to be elucidated is whether the survival impact seen in this study was due to the shorter time to surgery or whether the effect was really due to a shorter time to systemic therapy. This study excluded patients receiving neoadjuvant therapy and only evaluated patients who had a single surgical intervention. Whether patients who had re-excisions or surgical complications such that they had a longer time before starting systemic therapy had a worse survival remains unanswered in this study.
Still, these data suggest that our efficiency in avoiding unnecessary delays to surgical treatment of breast cancer may be associated with better outcomes.