In the Journals

Transfers of breast cancer care lead to treatment delays that may impact outcomes

Richard Bleicher, MD, FACS
Richard Bleicher

Women with newly diagnosed breast cancer who transferred care between institutions risked delays in surgery or other forms of treatment, which could negatively affect compliance with time-based quality standards, according to study results published in Breast Cancer Research and Treatment.

Researchers, however, said they do not want to diminish the potential value of second opinions.

“It is important for patients to understand that small delays will not impact their outcomes, but once the delays are on the order of months, an impact could start to occur,” Richard J. Bleicher MD, FACS, leader of the breast cancer program and professor in the department of surgical oncology at Fox Chase Cancer Center, told HemOnc Today. “Because delays can sometimes be unpredictable, and the need for further workup when transferring care can sometimes occur, it is important not to delay unnecessarily. [It’s also] important for them to be aware that if they get multiple opinions, especially more than two, they must weigh the impact that the delay from those opinions may have as vs. the value of getting those additional opinions.”

Currently, there is no standard guideline on how quickly a patient should undergo surgery after being diagnosed with breast cancer. However, several organizations, such as ASCO and the American College of Surgeons’ National Accreditation Program for Breast Cancers, endorse time-dependent quality measures that include:

Starting chemotherapy less than 120 days after diagnosis for women aged younger than 70 years with AJCC T1c, stage II or stage III, hormone receptor-negative disease;

Starting radiation less than 365 days after diagnosis for women aged younger than 70 years having breast conservation surgery; and

Starting endocrine therapy less than 365 days after diagnosis for women with AJCC T1c, stage II or stage III, hormone receptor-positive disease.

Bleicher and colleagues sought to evaluate the frequency and impact of transfers of care on time to surgery and the effect on the time-based quality measures.

The researchers analyzed data from 633,793 patients with nonmetastatic invasive breast cancer diagnosed between 2006 and 2015 at reporting facilities in the National Cancer Database.

Among these patients, 36.6% transferred care between diagnosis and surgery. The transfer of care added an average of 7.3 days (95% CI, 7.1-7.4) to time to surgery, 7.8 days (95% CI, 7.4-8.2) to time to chemotherapy, 8.7 days (95% CI, 8.1-9.2) to time to radiotherapy, and 9.8 days (95% CI, 9.2-10.4) to time to endocrine therapy (P < .0001 for all).

Younger patients, Hispanic patients, patients with non-Medicare governmental insurance and those having bilateral mastectomy appeared more likely to transfer care, whereas black patients, uninsured patients and those from urban and poor areas appeared less likely to transfer.

The odds of having surgery beyond 90 days of diagnosis appeared highest for those undergoing unilateral mastectomy (OR = 2.23; 95% CI, 2.13-2.33) or bilateral mastectomy (OR = 3.14, 95% CI, 2.99-3.3), black patients (OR = 2.69; 95% CI, 2.56-2.83), Hispanic patients (OR = 1.94; 95% CI 1.8-2.07), and patients who transferred care (OR = 1.77; 95% CI, 1.7-1.83).

A transfer of care increased the odds of noncompliance with time-based quality measures by 65.4% per patient for chemotherapy, 56.5% per patient for endocrine therapy, and 25.6% per patient for radiotherapy.

Bleicher and colleagues wrote that they do not recommend prohibiting or discouraging second opinions or transfers, but suggest that institutions consider ways to expedite the treatment process for patients who have waited for a long time.

“Although the time added by transferring care is small, on top of this there may be obstacles to care that transferring patients may face that increase the time from diagnosis, such as the need to obtain their medical records, slides and films from outside institutions and have those reviewed at the new institution,” Bleicher said. “Institutions should try to optimize these processes so that patient’s time to treatment and their outcomes are minimally impacted. Clinicians will not have control over some of this, but awareness of the impact is the first step to minimizing it.” – by John DeRosier

For more information:

Richard Bleicher, MD,FACS can be reached at Fox Chase Cancer Center, 333 Cottman Ave., Philadelphia, PA 19111.

Disclosures: The authors report no relevant financial disclosures.

Richard Bleicher, MD, FACS
Richard Bleicher

Women with newly diagnosed breast cancer who transferred care between institutions risked delays in surgery or other forms of treatment, which could negatively affect compliance with time-based quality standards, according to study results published in Breast Cancer Research and Treatment.

Researchers, however, said they do not want to diminish the potential value of second opinions.

“It is important for patients to understand that small delays will not impact their outcomes, but once the delays are on the order of months, an impact could start to occur,” Richard J. Bleicher MD, FACS, leader of the breast cancer program and professor in the department of surgical oncology at Fox Chase Cancer Center, told HemOnc Today. “Because delays can sometimes be unpredictable, and the need for further workup when transferring care can sometimes occur, it is important not to delay unnecessarily. [It’s also] important for them to be aware that if they get multiple opinions, especially more than two, they must weigh the impact that the delay from those opinions may have as vs. the value of getting those additional opinions.”

Currently, there is no standard guideline on how quickly a patient should undergo surgery after being diagnosed with breast cancer. However, several organizations, such as ASCO and the American College of Surgeons’ National Accreditation Program for Breast Cancers, endorse time-dependent quality measures that include:

Starting chemotherapy less than 120 days after diagnosis for women aged younger than 70 years with AJCC T1c, stage II or stage III, hormone receptor-negative disease;

Starting radiation less than 365 days after diagnosis for women aged younger than 70 years having breast conservation surgery; and

Starting endocrine therapy less than 365 days after diagnosis for women with AJCC T1c, stage II or stage III, hormone receptor-positive disease.

Bleicher and colleagues sought to evaluate the frequency and impact of transfers of care on time to surgery and the effect on the time-based quality measures.

The researchers analyzed data from 633,793 patients with nonmetastatic invasive breast cancer diagnosed between 2006 and 2015 at reporting facilities in the National Cancer Database.

Among these patients, 36.6% transferred care between diagnosis and surgery. The transfer of care added an average of 7.3 days (95% CI, 7.1-7.4) to time to surgery, 7.8 days (95% CI, 7.4-8.2) to time to chemotherapy, 8.7 days (95% CI, 8.1-9.2) to time to radiotherapy, and 9.8 days (95% CI, 9.2-10.4) to time to endocrine therapy (P < .0001 for all).

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Younger patients, Hispanic patients, patients with non-Medicare governmental insurance and those having bilateral mastectomy appeared more likely to transfer care, whereas black patients, uninsured patients and those from urban and poor areas appeared less likely to transfer.

The odds of having surgery beyond 90 days of diagnosis appeared highest for those undergoing unilateral mastectomy (OR = 2.23; 95% CI, 2.13-2.33) or bilateral mastectomy (OR = 3.14, 95% CI, 2.99-3.3), black patients (OR = 2.69; 95% CI, 2.56-2.83), Hispanic patients (OR = 1.94; 95% CI 1.8-2.07), and patients who transferred care (OR = 1.77; 95% CI, 1.7-1.83).

A transfer of care increased the odds of noncompliance with time-based quality measures by 65.4% per patient for chemotherapy, 56.5% per patient for endocrine therapy, and 25.6% per patient for radiotherapy.

Bleicher and colleagues wrote that they do not recommend prohibiting or discouraging second opinions or transfers, but suggest that institutions consider ways to expedite the treatment process for patients who have waited for a long time.

“Although the time added by transferring care is small, on top of this there may be obstacles to care that transferring patients may face that increase the time from diagnosis, such as the need to obtain their medical records, slides and films from outside institutions and have those reviewed at the new institution,” Bleicher said. “Institutions should try to optimize these processes so that patient’s time to treatment and their outcomes are minimally impacted. Clinicians will not have control over some of this, but awareness of the impact is the first step to minimizing it.” – by John DeRosier

For more information:

Richard Bleicher, MD,FACS can be reached at Fox Chase Cancer Center, 333 Cottman Ave., Philadelphia, PA 19111.

Disclosures: The authors report no relevant financial disclosures.