Influence of delay to diagnosis on prognostic indicators of screen-detected breast carcinoma

Comparisons of assessment pathways after abnormal mammography screening in Denmark, Norway, and Spain

PURPOSE

To ensure high-quality screening programmes and effective utilization of resources, it is important to monitor how cancer detection is affected by different strategies performed at recall assessment. This study aimed to describe procedures performed at recall assessment and compare and evaluate the performance of the assessment in Denmark, Norway, and Spain in terms of screen-detected cancer (SDC) and interval cancer (IC) rates.

METHODS

We included women aged 50-69 years from Denmark, Norway, and Spain, who were recalled for assessment after screening mammography, and recorded all procedures performed during six months after diagnosis, and the timing of the procedures. Women were followed for two years and screen-detected and interval cancer, and sensitivity of recall was calculated and compared.

RESULTS

In total, data from 24,645 Danish, 30,050 Norwegian, and 41,809 Spanish women were included in the study. Most of the women had some assessment within 2 months in all three countries. SDC rates were higher in Denmark (0.57) and Norway (0.60) compared to Spain (0.38), as were the IC rates, i.e. 0.25 and 0.18 vs. 0.12, respectively. The sensitivity of the diagnostic follow-up was somewhat higher in Denmark (98.3%) and Norway (98.2%), compared to Spain (95.4%), but when excluding non-invasive assessment pathways, the sensitivities were comparable.

CONCLUSION

This comparison study showed variation in the assessment procedures used in the three countries as well as the SDC and IC rates and the sensitivity of recall.

Latent pathway-based Bayesian models to identify intervenable factors of racial disparities in breast cancer stage at diagnosis

PURPOSE

We built Bayesian Network (BN) models to explain roles of different patient-specific factors affecting racial differences in breast cancer stage at diagnosis, and to identify healthcare related factors that can be intervened to reduce racial health disparities.

METHODS

We studied women age 67-74 with initial diagnosis of breast cancer during 2006-2014 in the National Cancer Institute's SEER-Medicare dataset. Our models included four measured variables (tumor grade, hormone receptor status, screening utilization and biopsy delay) expressed through two latent pathways-a tumor biology path, and health-care access/utilization path. We used various Bayesian model assessment tools to evaluate these two latent pathways as well as each of the four measured variables in explaining racial disparities in stage-at-diagnosis.

RESULTS

Among 3,010 Black non-Hispanic (NH) and 30,310 White NH breast cancer patients, respectively 70.2% vs 76.9% were initially diagnosed at local stage, 25.3% vs 20.3% with regional stage, and 4.56% vs 2.80% with distant stage-at-diagnosis. Overall, BN performed approximately 4.7 times better than Classification And Regression Tree (CART) (Breiman L, Friedman JH, Stone CJ, Olshen RA. Classification and regression trees. CRC press; 1984) in predicting stage-at-diagnosis. The utilization of screening mammography is the most prominent contributor to the accuracy of the BN model. Hormone receptor (HR) status and tumor grade are useful for explaining racial disparity in stage-at diagnosis, while log-delay in biopsy impeded good prediction.

CONCLUSIONS

Mammography utilization had a significant effect on racial differences in breast cancer stage-at-diagnosis, while tumor biology factors had less impact. Biopsy delay also aided in predicting local and regional stages-at-diagnosis for Black NH women but not for white NH women.

Improving Time to Diagnostic Resolution in the Breast Imaging Service: A Tertiary Center's Experience and Process of Improvement

OBJECTIVE

Breast imaging services often experience a significant degree of variability in patient flow, leading to delay in time to diagnostic resolution, commonly referred to as time to resolution (TTR). This study applies Lean Six Sigma Methodology (LSSM) to reduce TTR and enhance patient outcomes.

METHODS

This study was IRB-approved. A baseline audit was done using cases of mammographic recalls (BI-RADS 0) to measure baseline TTR. Multidisciplinary meetings with all members of the breast imaging service, alongside a study of patient complaint data, were utilized to identify issues that were causing prolonged TTR. Following that, possible solutions were proposed and implemented. A post-implementation audit was conducted, and the resulting TTRs were compared. Significant differences in TTR between the pre- and post-solution implementation were assessed using the Mann-Whitney U test.

RESULTS

During the baseline audit of 8 months, 589 cases of mammographic recalls (BI-RADS 0) were identified, and the resulting average TTR was 86.3 days. During the post-implementation period of 3 months, 370 mammographic recalls (BI-RADS 0) occurred, with a resulting average TTR of 36.0 days. After applying LSSM, TTR was reduced by 58.3% (P < 0.01). Some changes implemented included training the coordinators, establishing a rapid diagnostic clinic using previously underutilized equipment, and having radiologists assigned full-time to the breast imaging service.

CONCLUSION

Our team has successfully managed to identify various causes behind the prolonged TTR using LSSM. Team collaboration was essential to study and decide on a more achievable TTR.

Factors Associated with the Breast Cancer Diagnostic Interval across Five Canadian Provinces: A CanIMPACT Retrospective Cohort Study

The cancer diagnostic process can be protracted, and it is a time of great anxiety for patients. The objective of this study was to examine inter- and intra-provincial variation in diagnostic intervals and explore factors related to the variation. This was a multi-province retrospective cohort study using linked administrative health databases. All females with a diagnosis of histologically confirmed invasive breast cancer in British Columbia (2007-2010), Manitoba (2007-2011), Ontario (2007-2010), Nova Scotia (2007-2012), and Alberta (2004-2010) were included. The start of the diagnostic interval was determined using algorithms specific to whether the patient's cancer was detected through screening. We used multivariable quantile regression analyses to assess the association between demographic, clinical and healthcare utilization factors with the diagnostic interval outcome. We found significant inter- and intra-provincial variation in the breast cancer diagnostic interval and by screen-detection status; patients who presented symptomatically had longer intervals than screen-detected patients. Interprovincial diagnostic interval variation was 17 and 16 days for screen- and symptom-detected patients, respectively, at the median, and 14 and 41 days, respectively, at the 90th percentile. There was an association of longer diagnostic intervals with increasing comorbid disease in all provinces in non-screen-detected patients but not screen-detected. Longer intervals were observed across most provinces in screen-detected patients living in rural areas. Having a regular primary care provider was not associated with a shorter diagnostic interval. Our results highlight important findings regarding the length of the breast cancer diagnostic interval, its variation within and across provinces, and its association with comorbid disease and rurality. We conclude that diagnostic processes can be context specific, and more attention should be paid to developing tailored processes so that equitable access to a timely diagnosis can be achieved.

Decreasing the Interval Wait Times for Screening Mammogram Results Using the "Reflex Testing" Algorithm

OBJECTIVE

The purpose of this analysis was to determine whether our "reflex testing" (RefT) intervention, implemented to address barriers in scheduling, communication, and diagnostic order placement for resolving BI-RADS 0 screening mammograms, resulted in decreased interval wait times (IWT) for patients with abnormal screening mammograms (abSM).

METHODS

All BI-RADS 0 cases over two six-month periods (pre-RefT and post-RefT) were analyzed. Timelines were generated for each BI-RADS 0 case. Elapsed days were computed from date of BI-RADS 0 report to the date of biopsy, additional diagnostic testing, and final resolution. The means of each endpoint within the pre-RefT and post-RefT cohorts were statistically analyzed using Pearson chi-square analysis to assess whether IWT differed significantly after RefT implementation.

RESULTS

The analytic cohort consisted of 1523 BI-RADS 0 cases (n(pre-RefT) = 647, n(post-RefT) = 876). Reflex testing decreased the overall mean IWT from 23.5 to 8.2 days (P < 0.001). For patients not requiring biopsy (1190/1523, 78.1%), the mean IWT from the BI-RADS 0 designation to first diagnostic test or resolution decreased from 29.7 to 10.8 days (P < 0.010). For patients who had biopsy (333/1523, 21.9%), RefT significantly decreased the IWT from BI-RADS 0 to first diagnostic test from 31.4 to 7.7 days (P < 0.001) and also significantly decreased the IWT from first diagnostic test to biopsy (20.9 to 17.7 days; P < 0.013).

CONCLUSION

Reflex testing intervention streamlines the workflow and significantly decreases IWT for resolving BI-RADS 0 abSM. The RefT intervention could be considered to improve efficiency at other breast centers.

Delays in Follow-up Care for Abnormal Mammograms in Mobile Mammography Versus Fixed-Clinic Patients

BACKGROUND

Mobile mammographic services (MM) have been shown to increase breast cancer screening in medically underserved women. However, little is known about MM patients' adherence to follow-up of abnormal mammograms and how this compares with patients from traditional, fixed clinics.

OBJECTIVES

To assess delays in follow-up of abnormal mammograms in women screened using MM versus fixed clinics.

DESIGN

Electronic medical record review of abnormal screening mammograms.

SUBJECTS

Women screened on a MM van or at a fixed clinic with an abnormal radiographic result in 2019 (N = 1,337).

MAIN MEASURES

Our outcome was delay in follow-up of an abnormal mammogram of 60 days or greater. Guided by Andersen's Behavioral Model of Health Services Utilization, we assessed the following: predisposing (age, ethnicity, marital status, preferred language), enabling (insurance, provider referral, clinic site), and need (personal breast cancer history, family history of breast/ovarian cancer) factors.

KEY RESULTS

Only 45% of MM patients had obtained recommended follow-up within 60 days of an abnormal screening compared to 72% of fixed-site patients (p < .001). After adjusting for predisposing, enabling, and need factors, MM patients were 2.1 times more likely to experience follow-up delays than fixed-site patients (CI: 1.5-3.1; p < .001). African American (OR: 1.5; CI: 1.0-2.1; p < .05) and self-referred (OR: 1.8; CI: 1.2-2.8; p < .01) women were significantly more likely to experience delays compared to Non-Hispanic White women or women with a provider referral, respectively. Women who were married (OR: 0.63; CI: 0.5-0.9; p < .01), had breast cancer previously (OR: 0.37; CI: 0.2-0.8; p < .05), or had a family history of breast/ovarian cancer (OR: 0.76; CI: 0.6-0.9; p < .05) were less likely to experience delayed care compared to unmarried women, women with no breast cancer history, or women without a family history of breast/ovarian cancer, respectively.

CONCLUSIONS

A substantial proportion of women screened using MM had follow-up delays. Women who are African American, self-referred, or unmarried are particularly at risk of experiencing delays in care for an abnormal mammogram.

Prevalência e fatores associados ao diagnóstico de câncer de mama em estágio avançado

Resumo Este estudo transversal investigou a prevalência e os fatores associados ao diagnóstico de câncer de mama em estágio avançado entre 18.890 mulheres assistidas em hospital especializado da capital do Rio de Janeiro, Brasil, entre os anos 1999 e 2016. Utilizou-se regressão de Poisson com variância robusta para estimar razões de prevalência e respectivos intervalos de 95% de confiança. Apresentaram maiores prevalências de diagnóstico nessa condição mulheres com idade entre 20-39 e 40-49 anos, de raça/cor da pele preta e parda, que viviam sem companheiro(a), procedentes de outros municípios do estado do Rio de Janeiro, que tiveram o Sistema Único de Saúde como origem do encaminhamento e que foram diagnosticadas nos sexênios 1999-2004 e 2005-2010. Em contrapartida, mulheres com idade entre 60-69 e 70-99 anos, que cursaram algum nível de escolaridade, com histórico familiar de câncer e que chegaram ao hospital com diagnóstico e sem tratamento apresentaram menores prevalências de diagnóstico em estágio avançado. Esses resultados podem ser considerados no planejamento de ações de prevenção secundária, a fim de antecipar o diagnóstico de câncer de mama dos grupos mais vulneráveis e assim colaborar para a redução da prevalência do diagnóstico em estágio avançado.

Diagnostics in Patients Suspect for Breast Cancer in The Netherlands

The goal of this study was to describe the variation in hospital-based diagnostic care activities for patients with symptomatology suspect for breast cancer in The Netherlands. Two cohorts were included: the ‘benign’ cohort (30,334 women suspected of, but without breast cancer) and the ‘malignant’ cohort (2236 breast cancer patients). Hospital-based financial data was combined with tumor data (malignant cohort) from The Netherlands Cancer Registry. Patterns within diagnostic pathways were analyzed. Factors influencing the number of visits and number of diagnostic care activities until diagnosis were identified in the malignant cohort with multivariable Cox and Poisson regression models. Compared to patients with benign diagnosis, patients with malignant disease received their diagnosis less frequently in one day, after an equal average number of hospital visits and higher average number of diagnostic activities. Factors increasing the number of diagnostic care activities were the following: lower age and higher cM-and cN-stages. Factors increasing the number of days until (malignant) diagnosis were as follows: higher BIRADS-score, screen-detected and higher cN-and cT-stages. Hospital of diagnosis influenced both number of activities and days to diagnosis. The diagnostic care pathway of patients with malignant disease required more time and diagnostic activities than benign disease and depends on hospital, tumor and patient characteristics.

Variations in pathways and resource use in follow-up after abnormal mammography screening: a nationwide register-based study

PURPOSE

Mammography screening reduces breast cancer mortality, but a successful screening programme depends on both high participation and a sufficient follow-up of abnormalities. This study investigated patterns of follow-up after abnormal screening mammography in Denmark, and whether the variation was associated with health care resource use.

METHODS

We included 19,458 women aged 50-69 years with an abnormal screening mammography during a 3-year period of 2014-2016. Women were followed until the end of 2018. Their follow-up pathway was categorized in terms of the timeliness, appropriateness (i.e. whether all recommended diagnostic tests were utilized), and the ratio of benign vs. malignant surgeries. Further, we estimated health care resource use including post-diagnostic imaging and surgery procedures.

RESULTS

Ninety-seven percent of women had a diagnostic follow-up test within 6 months and 94% of those had diagnostic procedures in accordance with the recommendations. The proportion with timely follow-up (i.e. within 1 month) was 83%, but varied significantly between administrative regions (p < 0.001), and also between women with a screen-detected cancer and those with a false-positive mammogram (87% vs. 81%, p < 0.001). The ratio between having a benign versus a malignant surgery was 1:8, but it varied depending on which tests were used for diagnosis. The average number of procedures was, generally, in accordance with the recommendations.

CONCLUSION

In most cases, follow-up after abnormal screening mammography followed national recommendations. We nevertheless found that this was not always the case in certain subgroups and administrative regions.

Diagnostic interval for non-screening patients undergoing mammography during the COVID-19 pandemic

Objective

During the COVID-19 pandemic, there was a temporary cessation of mammography screening. However, in some facilities, diagnostic breast imaging services continued for patients with a high clinical suspicion of breast cancer. The objective of this study was to evaluate changes in the diagnostic interval (DI) of non-screening patients presenting for diagnostic mammography during the first wave of the COVID-19 pandemic.

Methods

Retrospective chart review was performed on patients presenting for non-screening diagnostic mammography from April 1 to June 30, 2020 (pandemic group) and April 1 to June 30, 2019 (pre-pandemic group). Age, reason for referral, number and type of imaging studies/biopsies necessary for a final diagnosis were recorded. Diagnostic interval (DI) was defined as the number of days from the date of the diagnostic mammogram to the date of the final diagnosis.

Results

Compared to the pre-pandemic group (n = 64), the pandemic group (n = 77) showed a reduction in DI of the entire cohort (pandemic: 1 day; pre-pandemic: 15 days, p < 0.0001) for patients not requiring tissue sampling (pandemic: 1 day; pre-pandemic: 11 days, .p < 0.0001) and those requiring tissue sampling with benign pathology (pandemic 9 days; pre-pandemic, 33 days, p = 0.0002). A higher percentage of patients in the pandemic group had their assessment completed during the initial visit (pandemic: 50.6%; pre-pandemic: 23.4%, p = 0.0009).

Conclusion

During the first wave of the COVID-19 pandemic, the DI for patients with non-screening-related diagnostic mammography was significantly shorter, with a higher percentage of patients completing their assessments on the initial visit, compared to one year prior.

Key Points

• Despite reductions in manpower and clinical services, during pandemic times, it is possible to maintain a diagnostic breast imaging service for women at high clinical suspicion for breast cancer.

• During pandemic times, breast imaging departments should consider restructuring to a Rapid Diagnostic Unit model with a navigation team that follows patients through the assessment process to a final diagnosis.

• Departmental restructuring and patient navigation during pandemic times could either maintain or shorten the diagnostic interval for patients presenting for diagnostic mammography.

A Neoadjuvant Chemotherapy Trial for Early Breast Cancer is Impacted by COVID-19: Addressing Vaccination and Cancer Trials Through Education, Equity, and Outcomes

While COVID-19 vaccine distribution has addressed vulnerabilities related to age and comorbidities, there is a need to ensure vaccination of patients with cancer receiving experimental and routine treatment, where interruption of treatment by infection is likely to result in inferior outcomes. Among patients with cancer, those undergoing neoadjuvant chemotherapy (NAC) or adjuvant chemotherapy (Adj chemo) for early breast cancer (EBC) are at particularly high risk for inferior outcomes, in part, because optimal timing of chemotherapy is essential for promoting distant disease-free survival. COVID-19 data from the ongoing multicenter I-SPY 2 trial of NAC for EBC provides a window into the magnitude of the problem of treatment interruption, not only for the trial itself but also for routine Adj chemo. In the I-SPY 2 trial, 4.5% of patients had disruption of therapy by COVID-19, prior to wide vaccine availability, suggesting that nationally up to 5,700 patients with EBC were at risk for adverse outcomes from COVID-19 infection in 2020. To address this problem, vaccine education and public engagement are essential to overcome hesitancy, while equity of distribution is needed to address access. To accomplish these goals, healthcare organizations (HCO) need to not only call out disinformation but also engage the public with vaccine education and find common ground for vaccine acceptance, while partnering with state/local governments to improve efficiency of vaccine distribution. These approaches are important to improve trial access and to reduce susceptibility to COVID-19, as the pandemic could continue to impact access to clinical trials and routine cancer treatment.

Does the choice of care pathways matter in timely breast cancer care in Sri Lanka?

BACKGROUND

An understanding on the use of care pathways facilitates identification of timeliness in breast cancer care. Aims of this study were to describe different breast cancer care pathways used by female breast cancer patients in Sri Lanka and to identify whether they experienced timely breast cancer care.

METHODS

We conducted a cross-sectional study among 800 female breast cancer patients with a histological/ cytological confirmation, from four state cancer treatment centers. We conceptualized five different care pathways with essential care points and in-between time intervals to be explored using an interviewer administered tool. Dates were cross-checked with the medical record. The difference of time intervals spent in different care pathways was tested for significance using one-way ANOVA test.

RESULTS

Mean (SD) age was 55.5 (10.7) years. A vast majority of 98.4 % (n = 787) self-detected the breast lesion, while only 13 had been detected through screening. Following self-detection, two thirds (n = 473, 59.1 %, 95 % CI = 55.7-62.5) had first consulted a primary healthcare physician, and a third n = 287, 35.8 %, 95 % CI = 32.6-39.3) had consulted an appropriate specialist first. Presentation interval among those who visited an Ayurvedic physician first was significantly longer than other pathways (p < 0.0001). Diagnosis interval for those who consulted an appropriate consultant was significantly shorter than other pathways (p < 0.0001).

CONCLUSIONS

Women take up numerous care paths following self-detection of a breast lesion. Empowering women on appropriate care pathways and expanding dedicated breast clinics where women to be first seen by an appropriate specialist are likely to improve timely breast cancer care in Sri Lanka.

COVID-19: Safe Guidelines for Breast Imaging During the Pandemic

During the COVID-19 pandemic, breast imaging must be performed using safe practices. Balancing the need to avoid delays in the diagnosis of breast cancer while avoiding infection requires careful attention to personal protective equipment and physical distancing and vigilance to maintain these practices. The Canadian Society of Breast Imaging/Canadian Association of Radiologists guideline for breast imaging during COVID-19 is provided based on priority according to risk of breast cancer and impact of delaying treatment. A review of the best practices is presented that allow breast imaging during COVID-19 to maximize protection of patients, technologists, residents, fellows, and radiologists and minimize spread of the infection. The collateral damage of delaying diagnosis of breast cancer due to COVID-19 should be avoided when possible.

Delayed breast cancer diagnosis after repeated recall at biennial screening mammography: an observational follow-up study from the Netherlands

Background

Delay in detection of breast cancer may worsen tumour characteristics, with progression of tumour size and a higher risk of metastatic lymph nodes. The purpose of this study was to investigate delayed breast cancer diagnosis after repeated recall for the same mammographic abnormality at screening.

Methods

This was a retrospective study performed in two cohorts of women enrolled in a mammography screening programme in the Netherlands. All women aged 50−75 who underwent biennial screening mammography either between January 1, 1997 and December 31, 2006 (cohort 1) or between January 1, 2007 and December 31, 2016 (cohort 2) were included.

Results

The cohorts showed no difference in proportions of women with delayed breast cancer diagnosis of at least 2 years (2.2% versus 2.8%, P = 0.29). Most delays were caused by incorrect BI-RADS classifications after recall (74.2%). An increase in mean tumour size was seen when comparing sizes at initial false-negative recall and at diagnosis of breast cancer (P < 0.001).

Conclusions

The proportion of women with a long delay in breast cancer confirmation following repeated recall at screening mammography has not decreased during 20 years of screening. These delays lead to larger tumour size at detection and may negatively influence prognosis.

Secure Provider-to-Provider Communication With Electronic Health Record Messaging: An Educational Outreach Study

INTRODUCTION

With increasing electronic health record (EHR) use, providers are talking less with one another. Now, many rely on EHRs, informal emails, or texts, introducing fragmentation and new data security challenges with new communication strategies. We aimed to examine the impact of a physician champion educational outreach intervention to promote electronic provider-to-provider communication in a large academic multispecialty group.

METHODS

Physician champions provided educational outreach to 16 academic departments, using 10-minute case-based presentations. Online surveys assessed communication preferences and practices. Electronic health record queries counted EHR messaging use before and after intervention. Descriptive statistics compared responses by specialty (z-test). Paired responses with pre-post data were compared using chi-square tests. Time series analysis assessed EHR messaging rates before intervention versus after intervention.

RESULTS

Five hundred seventeen providers responded to the postoutreach survey. Eighty-six percent were familiar with EHR messaging tool and 78% knew how to use it after intervention. Among practitioner groups, Family Medicine preferred EHR messaging the most (62%). Groups who declined outreach least preferred it (26%). Among 88 respondents with paired pre-post intervention surveys, familiarity rose (79-96%), and self-reported use increased (66-88%).

CONCLUSIONS

Physician champion educational outreach increased the use of the secure provider-to-provider EHR messaging tool.

Improving Wait Times and Patient Experience Through Implementation of a Provincial Expedited Diagnostic Pathway for BI-RADS 5 Breast Lesions

BACKGROUND

Long diagnostic intervals following abnormal breast imaging (DI) cause patient anxiety and possibly poorer prognosis. This study evaluates the effect of a provincial diagnostic pathway for BI-RADS 5 lesions on wait times and the patient-reported experience (PRE).

METHODS

With multidisciplinary input, we developed a pathway for BI-RADS 5 lesions featuring expedited biopsy, early surgical referral, and nurse (RN) navigator support. Key diagnostic intervals were captured prospectively and compared with a prepathway control cohort. PRE data were obtained from a voluntary survey.

RESULTS

1205 patients were managed on the BI-RADS 5 pathway with 797 primary care physicians, 57 imaging centers, and 2 regional breast programs participating. Median duration from DI to biopsy was 6 days, from biopsy to pathology report was 5 days, DI to surgical referral was 6 days, and DI to surgical consult was 21 days. Compared with 128 prepathway controls, median intervals from DI to surgical referral and consult were significantly improved (15 vs. 6 days, 26 vs. 21 days, p < 0.001). Amongst 294 women who completed the survey, 92% experienced ≥ 1 anxiety complaint during assessment; prompt surgical consultation and multiple features of RN support reduced anxiety, and wait time satisfaction was high (70%). Patient preferences varied for receiving biopsy results from a surgeon (57%) vs. another provider (43%).

CONCLUSIONS

A diagnostic pathway for BI-RADS 5 lesions reduced wait times and improved the patient experience through prompt surgical referral and RN navigator support. Differing preferences for receiving biopsy results emerged, and future iterations should incorporate individualized patient wishes.

Healthcare delay in breast cancer patients: a case study in a low-density population region from Mexico

Aim: To describe delay intervals, their impact on clinical stage and initiation of first oncologic treatment, and evaluate associated factors in breast cancer patients in Yucatan, Mexico, a low-density population region. Patients & methods: A retrospective analysis was done of 92 medical records, and bivariate and multivariate models applied to identify associations between healthcare delay and several factors. Results: System delay accounted for most of the delay (median: 86 days; 61% of delay). Socioeconomic status and delivery to tertiary-care hospital predicted delay. Clinical stage determined initiation of first oncologic treatment. Conclusion: Delay in treatment was largely due to system delay. Only a few variables explained this delay. Clinical stage had the strongest effect on initiation of first oncologic treatment.

The impact of organized breast assessment on survival by stage for screened women diagnosed with invasive breast cancer

PURPOSE

Since 1998, the Ontario Breast Screening Program (OBSP) has offered organized assessment through Breast Assessment Centres (BAC). This study compares survival between screened women diagnosed with breast cancer who have undergone assessment through a BAC and usual care (UC).

METHODS

A retrospective design identified two concurrent cohorts of women aged 50 to 69 within the OBSP diagnosed with screen-detected invasive breast cancer at a BAC (n = 2010) and UC (n = 1844) between 2002 and 2010 and followed until 2016. Demographic and assessment characteristics were obtained from the OBSP. Abstraction of medical charts provided prognostic and treatment data. Death data were assessed from the Registered Person's Database and the Ontario Registrar General All-Cause Mortality File. Multivariable Cox proportional hazards models compared overall survival by assessment type (BAC/UC), stratified by stage.

RESULTS

There were 505 deaths during the study (BAC = 239; UC = 266). Among women with stage I screen-detected breast cancer, those diagnosed through a BAC had 31% reduced risk of all-cause mortality (HR = 0.69, 95% CI = 0.53-0.90) compared to UC. Diagnosis within 7 weeks of an abnormal mammogram reduced the hazard of death from all causes by 34% among all women with stage I breast cancers (HR = 0.66, 95% CI = 0.47-0.91), and was more likely in BAC (79.7%) than UC (66.9%).

CONCLUSION

The significant improvement in overall survival for women with stage I screen-detected invasive breast cancer assessed through BACs further supports the recommendation that women with abnormal mammograms should be managed through organized assessment.

Timely follow-up of positive cancer screening results: A systematic review and recommendations from the PROSPR Consortium

Timely follow-up for positive cancer screening results remains suboptimal, and the evidence base to inform decisions on optimizing the timeliness of diagnostic testing is unclear. This systematic review evaluated published studies regarding time to follow-up after a positive screening for breast, cervical, colorectal, and lung cancers. The quality of available evidence was very low or low across cancers, with potential attenuated or reversed associations from confounding by indication in most studies. Overall, evidence suggested that the risk for poorer cancer outcomes rises with longer wait times that vary within and across cancer types, which supports performing diagnostic testing as soon as feasible after the positive result, but evidence for specific time targets is limited. Within these limitations, we provide our opinion on cancer-specific recommendations for times to follow-up and how existing guidelines relate to the current evidence. Thresholds set should consider patient worry, potential for loss to follow-up with prolonged wait times, and available resources. Research is needed to better guide the timeliness of diagnostic follow-up, including considerations for patient preferences and existing barriers, while addressing methodological weaknesses. Research is also needed to identify effective interventions for reducing wait times for diagnostic testing, particularly in underserved or low-resource settings. CA Cancer J Clin 2018;68:199-216. © 2018 American Cancer Society.

Combination of SIRT1 and Src overexpression suggests poor prognosis in luminal breast cancer

Objectives

1) Analyze the correlation of SIRT1 and Src with human breast cancer (BC) prognosis; 2) explore the roles of SIRT1 and Src in BC cell proliferation, tumor invasion, and metastasis; and 3) analyze the correlation and interaction between SIRT1 and Src.

Materials and methods

1) Tissue microarray was used to analyze the expression of SIRT1 and Src in human BC tissues and the correlation between protein expression and cancer prognosis; 2) CCK8 assay was used to determine the influence of SIRT1 and Src inhibitors on BC cell proliferation; 3) Transwell migration assay and wound healing assay were used to determine the effect of SIRT1 and Src inhibitors on BC cell migration and invasion; and 4) Western blotting was used to analyze the correlation and interaction between SIRT1 and Src.

Results

1) Combination of SIRT1 and/or Src positivity is a prognosis factor in BC, especially in luminal type; 2) MCF-7 cell proliferation is suppressed by SIRT1 inhibitor Ex527, and cell migration and invasion were inhibited by Src inhibitor bosutinib; 3) combined with Ex527, bosutinib has a significantly increased effect on MCF-7 cell migration suppression; and 4) there is a positive association between SIRT1 and Src both in BC tissues and in MCF-7 cells.

Conclusion

1) SIRT1 and Src overexpression are both correlated with poor prognosis in human BC; 2) SIRT1 + Src (SIRT1 and/or Src positivity) is a fine prognosis model for luminal-type BC; 3) SIRT1 is a copromotor of Src in BC migration and invasion, but not in cell proliferation; and 4) our results suggest a potential interaction or a common regulation pathway between SIRT1 and Src expression and activity.

Disparities in abnormal mammogram follow-up time for Asian women compared with non-Hispanic white women and between Asian ethnic groups

BACKGROUND

Delays in abnormal mammogram follow-up contribute to poor outcomes. In the current study, the authors examined differences in abnormal screening mammogram follow-up between non-Hispanic white (NHW) and Asian women.

METHODS

The authors used a prospective cohort of NHW and Asian women with a Breast Imaging, Reporting and Data System (BI-RADS) abnormal result of category 0 or 3-plus in the San Francisco Mammography Registry between 2000 and 2010. Kaplan-Meier estimation for the median number of days to follow-up with a diagnostic radiologic test was performed, and the authors compared the percentage of women with follow-up at 30 days, 60 days, and 90 days and no follow-up at 1 year for Asian women overall (and Asian ethnic groups) and NHW women. In addition, the authors assessed the relationship between race/ethnicity and time to follow-up with adjusted Cox proportional hazards models.

RESULTS

Among Asian women, Vietnamese and Filipina women had the longest, and Japanese women the shortest, median follow-up (32 days, 28 days, and 19 days, respectively) compared with NHW women (15 days). The percentage of women receiving follow-up at 30 days was lower for Asians versus NHWs (57% vs 77%; P<.0001), and these disparities persisted at 60 days and 90 days for all Asian ethnic groups except Japanese. Asian women had a reduced hazard of follow-up compared with NHW women (adjusted hazard ratio, 0.70; 95% confidence interval, 0.69-0.72). Asian women also had a higher rate of receiving no follow-up compared with NHW women (15% vs 10%; P<.001); among Asian ethnic groups, Filipinas were found to have the highest percentage of women with no follow-up (18.1%).

CONCLUSIONS

Asian women, particularly Filipina and Vietnamese women, were less likely than NHW women to receive timely follow-up after an abnormal screening mammogram. Research should disaggregate Asian ethnicity to better understand and address barriers to effective cancer prevention. Cancer 2017;123:3468-75. © 2017 American Cancer Society.

Overexpression of cofilin correlates with poor survival in breast cancer: A tissue microarray analysis

Cofilin, a key regulator of actin cytoskeleton dynamics, is considered to be involved in cellular migration, tumor invasion and mitosis, and its activity is increased in cancer cells. To address the association between cofilin and breast cancer prognosis, which is unclear at present, cofilin expression was analyzed in tissue microarrays of tumors from 310 patients with breast cancer via immunohistochemistry. In a multivariate Cox regression analysis, a high expression of cofilin in tumor cells correlated significantly with shorter overall survival (hazard ratio, 2.22; 95% confidence interval, 1.35–3.66, P=0.002, and with the Nottingham histologic grade, Ki-67 status and human epidermal growth factor receptor 2 status (P=0.031, 0.001, and 0.001, respectively). Cofilin expression was not observed as correlated with estrogen or progesterone receptor expression, tumor size or lymph node status. These data demonstrate that cofilin is associated with poor outcome, thereby suggesting that it is a potential prognostic factor in breast cancer.

Timeliness of Breast Cancer Treatment in Delaware

Studies have shown timely screening, diagnosis, and treatment of breast cancer reduces mortality rates. The objective of this study is to evaluate the overall timeliness of breast cancer diagnosis and treatment for Delawarean women using the Centers for Disease Control and Prevention’s (CDC) National Breast and Cervical Cancer Early Detection Program’s (NBCCEDP) recommendations of 60 days maximum for screening to diagnosis and 60 days maximum for diagnosis to treatment. This study analyzed Delaware Cancer Registry (DCR) data for female Delawarean breast cancer patients diagnosed in 2010 who had valid screening, diagnosis, and treatment dates.

Calculations of three time intervals were performed: screening to diagnosis (Time A), diagnosis to treatment (Time B), and screening to treatment (Time C). The mean and median for Time Intervals A (21.2 days, 17.0 days), B (27.8 days, 25.0 days), and C (49.0 days, 42.0 days) met CDC recommendations. Our results show most Delawarean women who had valid screening, diagnosis, and treatment dates received a diagnosis within 60 days of screening and first course of treatment occurred within 60 days of diagnosis and therefore met the NBCCEDP recommendations.

Evaluating wait times from screening to breast cancer diagnosis among women undergoing organised assessment vs usual care

Background:

Timely coordinated diagnostic assessment following an abnormal screening mammogram reduces patient anxiety and may optimise breast cancer prognosis. Since 1998, the Ontario Breast Screening Program (OBSP) has offered organised assessment through Breast Assessment Centres (BACs). For OBSP women seen at a BAC, an abnormal mammogram is followed by coordinated referrals through the use of navigators for further imaging, biopsy, and surgical consultation as indicated. For OBSP women seen through usual care (UC), further diagnostic imaging is arranged directly from the screening centre and/or through their physician; results must be communicated to the physician who is then responsible for arranging any necessary biopsy and/or surgical consultation. This study aims to evaluate factors associated with diagnostic wait times for women undergoing assessment through BAC and UC.

Methods:

Of the 2 147 257 women aged 50–69 years screened in the OBSP between 1 January 2002 and 31 December 2009, 155 866 (7.3%) had an abnormal mammogram. A retrospective design identified two concurrent cohorts of women diagnosed with screen-detected breast cancer at a BAC (n=4217; 47%) and UC (n=4827; 53%). Multivariable logistic regression analyses examined associations between wait times and assessment and prognostic characteristics by pathway. A two-sided 5% significance level was used.

Results:

Screened women with breast cancer were two times more likely to be diagnosed within 7 weeks when assessed through a BAC vs UC (OR=1.91, 95% CI=1.73–2.10). In addition, compared with UC, women assessed through a BAC were significantly more likely to have their first assessment procedure within 3 weeks of their abnormal mammogram (OR=1.25, 95% CI=1.12–1.39), ⩽3 assessment procedures (OR=1.54, 95% CI=1.41–1.69), ⩽2 assessment visits (OR=1.86, 95% CI=1.70–2.05), and ⩾2 procedures per visit (OR=1.41, 95% CI=1.28–1.55). Women diagnosed through a BAC were also more likely than those in UC to have imaging (OR=1.99, 95% CI=1.44–2.75) or a biopsy (OR=3.69, 95% CI=2.64–5.15) vs consultation only at their first assessment visit, and two times more likely to have a core or FNA biopsy than a surgical biopsy (OR=2.08, 95% CI=1.81–2.40). Having ⩽2 assessment visits was more likely to reduce time to diagnosis for women assessed through a BAC compared with UC (BAC OR=10.58, 95% CI=8.96–12.50; UC OR=4.47, 95% CI=3.94–5.07), as was having ⩽3 assessment procedures (BAC OR=4.97, 95% CI=4.26–5.79; UC OR=2.95, 95% CI=2.61–3.33). Income quintile affected wait times only in women diagnosed in UC, with those in the two highest quintiles more likely to receive a diagnosis in 7 weeks.

Conclusions:

Women with screen-detected breast cancer in OBSP were more likely to have shorter wait times if they were diagnosed through organised assessment. This might be as a result of women diagnosed through a BAC having more procedures per visit, procedures scheduled in shorter intervals, and imaging or biopsy on their first visit. Given the significant improvement in timeliness to diagnosis, women with abnormal mammograms should be managed through organised assessment.

Survival Benefits of Treatment Access Among Underserved Breast Cancer Patients Diagnosed Through the Texas Breast and Cervical Cancer Services Program

PURPOSE

The Texas Breast and Cervical Cancer Services (BCCS) program was established to address socioeconomic disparities in breast and cervical cancer screening and survival. This study examined the impact of the program on treatment and survival of breast cancer patients.

METHODS

A retrospective analysis was performed using the Texas Cancer Registry data linked to the BCCS program data. The sample consisted of 40- to 64-year-old women screened and diagnosed with breast cancer through the BCCS program (participants) and similar women living in low socioeconomic status census tracts and diagnosed outside the program (comparison group) during 1995-2008. Regular screeners among the participants were also compared with the comparison group.

RESULTS

Participants had lower rates of breast surgery and higher rates of chemotherapy as compared with the comparison group. Participants undergoing surgery had higher rates of mastectomy (as compared with breast-conserving surgery) and lower rates of adjuvant radiation therapy. Unadjusted survival rates were similar between the participants and the comparison group, and higher among regular screeners, which was primarily driven by stage at diagnosis. Adjusted survival rates were similar between the 3 groups.

CONCLUSIONS

Although there are differences in the types of treatment provided to the participants and the comparison group, there is no evidence of guideline noncompliance or stage-inappropriate treatment provision in either of the groups. Despite being diagnosed with a more advanced stage, the participants had similar unadjusted and adjusted survival rates as the comparison group. Access to timely treatment improved survival and brought the underserved participants on par with the comparison group.

Dephosphorylated cofilin expression is associated with poor prognosis in cases of human breast cancer: a tissue microarray analysis

Background

Proteins in the cofilin pathway regulate actin dynamics and may be involved in cancer cell migration and invasion. However, there are no direct data that suggest that dephosphorylated cofilin can affect breast cancer prognosis.

Methods

We assessed the expressions of cofilin and phosphorylated cofilin (P-cofilin) in breast cancer tissue microarrays (290 patients, mean follow-up: 95.7±2.49 months) to evaluate dephosphorylated cofilin and its relationship with breast cancer prognosis. The associations of pathological characteristics with cumulative survival were evaluated using Kaplan–Meier analysis.

Results

Univariate analyses revealed that overall survival was associated with cofilin levels, N category, TNM stage, estrogen receptor status, progesterone receptor status, and molecular subtypes. Cofilin status and TNM stage independently affected overall survival, although P-cofilin expression was not associated with patient survival. In the P-cofilin-negative subgroup, cofilin expression was significantly associated with patient survival, although cofilin expression was not significantly associated with patient survival in the P-cofilin-positive subgroup. We further analyzed the P-cofilin-negative cases and found that Ki-67 expression was significantly elevated in the subgroup that was strongly positive for cofilin (P=0.002).

Conclusion

Among P-cofilin-negative patients with breast cancer, cofilin expression defines a population of patients with lower overall survival, which suggests that dephosphorylated cofilin expression might predict the prognosis in cases of P-cofilin-negative breast cancer. Furthermore, our results suggest that inhibitors of dephosphorylated cofilin expression may provide therapeutic benefits in patients with breast cancer.

Are disparities of waiting times for breast cancer care related to socio-economic factors? A regional population-based study (France)

The increasing number of breast cancer cases may induce longer waiting times (WT), which can be a source of anxiety for patients and may play a role in survival. The aim of this study was to examine the factors, in particular socio-economic factors, related to treatment delays. Using French Cancer Registry databases and self-administered questionnaires, we included 1,152 women with invasive non-metastatic breast cancer diagnosed in 2007. Poisson regression analysis was used to identify WTs' influencing factors. For 973 women who had a malignant tissue sampling, the median of overall WT between the first imaging procedure and the first treatment was 44 days (9 days for pathological diagnostic WT and 31 days for treatment WT). The medical factors mostly explained inequalities in WTs. Socio-economic and behavioral factors had a limited impact on WTs except for social support which appeared to be a key point. Better identifying the factors associated with increase in WTs will make it possible to develop further interventional or prospective studies to confirm their causal role in delay and at last reduce disparities in breast cancer management.

Time to Diagnostic Evaluation After Mammographic Screening in an Urban Setting

BACKGROUND

The Capital Breast Care Center (CBCC), a screening facility established to serve minority women, developed a culturally sensitive patient care paradigm that would address concerns of adherence to follow-up of abnormal results after initial mammogram. Women with abnormal mammograms are assigned a Black or Latina navigator who facilitates the additional workup needed by scheduling follow-up, arranging transportation, providing counsel/emotional support, and even accompanying them to diagnostic imaging or biopsy appointment. We present data on follow-up rates after breast cancer screening.

METHODS

All patients seen at CBCC are entered into a prospectively collected database. We calculated intervals (in days) between the screening and diagnostic visits. Descriptive statistics and median time to follow-up are reported. Differences between Black and Hispanic women on time interval were tested by t-test.

RESULTS

From January 2010 to December 2012, 4605 digital screening mammograms were performed. Fifty-two percent of the women self-identified as Black, 41% as Hispanic, 4% White, 2% Asian, and 1% as "other." Of the screening studies, 451 (9.8%) required additional workup, out of which 362 (80%) of the women returned for the recommended diagnostic imaging. The median interval between screening and diagnostic imaging was 39 days (range: 6-400). Of the 162 women recommended to have a core needle biopsy, 81.5% underwent biopsy within a median of 21 days (range: 0-221 days).

CONCLUSION

At the CBCC, time to patient follow-up after initial mammographic screening is within the CDC-recommended performance standard of less than 60 days. For a population that historically has low rates of clinical follow-up, we attribute this reduction in delays to breast cancer diagnostic resolution to a culturally sensitive patient navigation program. Additional studies are needed to assess how the existing navigation program can be individualized/tailored to target the remaining 20% of women who did not adhere to the recommended workup.

Factors related to breast cancer detection mode and time to diagnosis in Alberta, Canada: a population-based retrospective cohort study

Background

Understanding the factors affecting the mode and timeliness of breast cancer diagnosis is important to optimizing patient experiences and outcomes. The purposes of the study were to identify factors related to the length of the diagnostic interval and assess how they vary by mode of diagnosis: screen or symptom detection.

Methods

All female residents of Alberta diagnosed with first primary breast cancer in years 2004–2010 were identified from the Alberta Cancer Registry. Data were linked to Physician Claims and screening program databases. Screen-detected patients were identified as having a screening mammogram within 6-months prior to diagnosis; remaining patients were considered symptom-detected. Separate quantile regression was conducted for each detection mode to assess the relationship between demographic/clinical and healthcare factors.

Results

Overall, 38 % of the 12,373 breast cancer cases were screen-detected compared to 47 % of the screen-eligible population. Health region of residence was strongly associated with cancer detection mode. The median diagnostic interval for screen and symptom-detected cancers was 19 and 21 days, respectively. The variation by health region, however, was large ranging from an estimated median of 4 to 37 days for screen-detected patients and from 17 to 33 days for symptom-detected patients. Cancer stage was inversely associated with the diagnostic interval for symptom-detected cancers, but not for screen-detected cancers.

Conclusion

Significant variation by health region in both the percentage of women with screen-detected cancer and the length of the diagnostic interval for screen and symptom-detected breast cancers suggests there could be important differences in local breast cancer diagnostic care coordination.

Compliance with referrals to medical specialist care: patient and general practice determinants: a cross-sectional study

Background

In a gatekeeper system, primary care physicians and patients jointly decide whether or not medical specialist care is needed. However, it is the patient who decides to actually use the referral. Referral non-compliance could delay diagnosis and treatment. The objective of this study was to assess patient compliance with a referral to medical specialist care and identify patient and practice characteristics that are associated with it.

Methods

Observational study using data on 48,784 referrals to medical specialist care derived from electronic medical records of 58 general practices for the period 2008–2010. Referral compliance was based on claims data of medical specialist care. Logistic multilevel regression analyses were conducted to determine associations between patient and general practice characteristics and referral compliance.

Results

In 86.6 % of the referrals, patients complied. Patient and not practice characteristics were significantly associated with compliance. Patients from deprived urban areas and patients aged 18–44 years were less likely to comply, whereas patients aged 65 years and older were more likely to comply.

Conclusion

About 1 in 8 patients do not use their referral. These patients may not receive adequate care. Demographic and socio-economic factors appear to affect compliance. The results of this study may be used to make general practitioners more aware that some patients are more likely to be noncompliant with referrals.

Estudo do tempo entre o diagnóstico e início do tratamento do câncer de mama em idosas de um hospital de referência em São Paulo, Brasil

Resumo Objetivou-se analisar o tempo entre o diagnóstico e o início do tratamento e conhecer o perfil sociodemográfico e clínico de mulheres com 60 ou mais anos de idade, diagnosticadas com câncer de mama entre os anos de 2001 a 2006, no Hospital Pérola Byington, São Paulo. Trata-se de um estudo descritivo, com dados secundários e amostra de 1299 casos. Coletou-se variáveis sociodemográficas, clínicas e temporais. Formou-se dois grupos de mulheres utilizando a variável tempo, sendo o tempo entre o diagnóstico e o início do tratamento: “até e maior que 60 dias”. A média do tempo entre o diagnóstico e o início do tratamento foi de 74,7 dias (DP = 212,6), e o tempo mediano de 45 dias. As idosas sem o diagnóstico e sem o tratamento anterior levaram menos tempo para dar início ao tratamento (p = 0,001), bem como as mulheres com estadiamento do tumor na fase inicial, in situ e I (p = 0,001). O tempo foi significante para os desfechos de recidiva (p = 0,004) e metástase (p = 0,038). O diagnóstico e o tratamento estabelecidos garantiu às idosas menor tempo para o início da assistência devida. Melhorar a estruturação e o funcionamento dos serviços de saúde constitui fator imprescindível para o atendimento dos casos da doença de forma eficiente, um importante desafio para o Sistema Único de Saúde.

Impact of Age and Comorbidity on Cervical and Breast Cancer Literacy of African Americans, Latina, and Arab Women

This study examines the relationship between age, comorbidity, and breast and cervical cancer literacy in a sample of African American, Latina, and Arab women (N = 371) from Detroit, Michigan. The Age-adjusted Charlson Comorbidity Index (ACC) was used characterize the impact of age and comorbidity on breast and cervical cancer literacy. The relationship between ACC and breast and cervical cancer screening, and group differences, were assessed. There was a statistically significant difference between breast cancer literacy scores. ACC had a greater impact on breast cancer literacy for African Americans.

Determinants of advanced stage presentation of breast cancer in 87,969 Brazilian women

BACKGROUND

Breast cancer is commonly diagnosed at an advanced stage in Brazil.

AIM

Analyze the determinants of advanced staging in Brazilian women with breast cancer.

METHODS

Crosssectional study, including women diagnosed with breast cancer in Brazil, between 2000 and 2009.

RESULTS

A total of 59,317 women were included, 53.5% being classified as advanced stage (≥IIB). Younger age (18 to 49 years old) (OR=1.61 95% CI 1.51 to 1.72) or between 40 and 49 years old (OR=1.08 95% CI 1.03 to 1.14), having low educational level (OR=1.53 95% CI 1.48 to 1.58), living in less developed geographical regions (OR=1.27 95% CI 1.21 to 1.33), having invasive ductal carcinoma (OR=2.70 95% CI 2.56 to 2.84) and invasive lobular carcinoma (OR=2.63 95% CI 2.42 to 2.86) were associated with advanced breast cancer.

CONCLUSION

We conclude that future interventions should focus on these high risk groups.

Effect of specialized diagnostic assessment units on the time to diagnosis in screen-detected breast cancer patients

Background:

The duration of the cancer diagnostic process has considerable influence on patients' psychosocial well-being. Breast diagnostic assessment units (DAUs) in Ontario, Canada are designed to improve the quality and timeliness of care during a breast cancer diagnosis. We compared the diagnostic duration of patients diagnosed through a DAU vs usual care (UC).

Methods:

Retrospective population-based cohort study of 2499 screen-detected breast cancers (2011) using administrative health-care databases linked to the Ontario Cancer Registry. The diagnostic interval was measured from the initial screen to cancer diagnosis. Diagnostic assessment unit use was based on the biopsy and/or surgery hospital. We compared the length of the diagnostic interval between the DAU groups using multivariable quantile regression.

Results:

Diagnostic assessment units had a higher proportion of patients diagnosed within the 7-week target compared with UC (79.1% vs 70.2%, P<0.001). The median time to diagnosis at DAUs was 26 days, which was 9 days shorter compared with UC (95% CI: 6.4–11.6). This effect was reduced to 8.3 days after adjusting for all study covariates. Adjusted DAU differences were similar at the 75th and 90th percentiles of the diagnostic interval distribution.

Conclusions:

Diagnosis through an Ontario DAU was associated with a reduced time to diagnosis for screen-detected breast cancer patients, which likely reduces the anxiety and distress associated with waiting for a diagnosis.

Health system delay and its effect on clinical stage of breast cancer: Multicenter study

BACKGROUND

The objective of this study was to determine the correlation between health system delay and clinical disease stage in patients with breast cancer.

METHODS

This was a cross‐sectional study of 886 patients who were referred to 4 of the largest public cancer hospitals in Mexico City for the evaluation of a probable breast cancer. Data on time intervals, sociodemographic factors, and clinical stage at diagnosis were retrieved. A logistic regression model was used to estimate the average marginal effects of delay on the probability of being diagnosed with advanced breast cancer (stages III and IV).

RESULTS

The median time between problem identification and the beginning of treatment was 7 months. The subinterval with the largest delay was that between the first medical consultation and diagnosis (median, 4 months). Only 15% of the patients who had cancer were diagnosed with stage 0 and I disease, and 48% were diagnosed with stage III and IV disease. Multivariate analyses confirmed independent correlations for the means of problem identification, patient delay, health system delay, and age with a higher probability that patients would begin cancer treatment in an advanced stage.

CONCLUSIONS

In the sample studied, the majority of patients with breast cancer began treatment after a delay. Both patient delays and provider delays were associated with advanced disease. Research aimed at identifying specific access barriers to medical services is much needed to guide the design of tailored health policies that go beyond the promotion of breast care awareness and screening participation to include improvements in health services that facilitate access to timely diagnosis and treatment. Cancer 2015;121:2198–2206.

Both patient delays and provider delays are associated with higher probabilities of patients starting cancer treatment with advanced‐stage disease. Research aimed at identifying specific access barriers to medical services is much needed to guide the design of tailored health policies, especially in developing countries.

Challenges to the early diagnosis and treatment of breast cancer in developing countries

This critical review of the literature assembles and compares available data on breast cancer clinical stage, time intervals to care, and access barriers in different countries. It provides evidence that while more than 70% of breast cancer patients in most high-income countries are diagnosed in stages I and II, only 20%-50% patients in the majority of low- and middle-income countries are diagnosed in these earlier stages. Most studies in the developed world show an association between an advanced clinical stage of breast cancer and delays greater than three months between symptom discovery and treatment start. The evidence assembled in this review shows that the median of this interval is 30-48 d in high-income countries but 3-8 mo in low- and middle-income countries. The longest delays occur between the first medical consultation and the beginning of treatment, known as the provider interval. The little available evidence suggests that access barriers and quality deficiencies in cancer care are determinants of provider delay in low- and middle-income countries. Research on specific access barriers and deficiencies in quality of care for the early diagnosis and treatment of breast cancer is practically non-existent in these countries, where it is the most needed for the design of cost-effective public policies that strengthen health systems to tackle this expensive and deadly disease.

Creation of a diagnostic wait times measurement framework based on evidence and consensus

PURPOSE

Public reporting of wait times worldwide has to date focused largely on treatment wait times and is limited in its ability to capture earlier parts of the patient journey. The interval between suspicion and diagnosis or ruling out of cancer is a complex phase of the cancer journey. Diagnostic delays and inefficient use of diagnostic imaging procedures can result in poor patient outcomes, both physical and psychosocial. This study was designed to develop a framework that could be adopted for multiple disease sites across different jurisdictions to enable the measurement of diagnostic wait times and diagnostic delay.

METHODS

Diagnostic benchmarks and targets in cancer systems were explored through a targeted literature review and jurisdictional scan. Cancer system leaders and clinicians were interviewed to validate the information found in the jurisdictional scan. An expert panel was assembled to review and, through a modified Delphi consensus process, provide feedback on a diagnostic wait times framework.

RESULTS

The consensus process resulted in agreement on a measurement framework that identified suspicion, referral, diagnosis, and treatment as the main time points for measuring this critical phase of the patient journey.

CONCLUSIONS

This work will help guide initiatives designed to improve patient access to health services by developing an evidence-based approach to standardization of the various waypoints during the diagnostic pathway. The diagnostic wait times measurement framework provides a yardstick to measure the performance of programs that are designed to manage and expedite care processes between referral and diagnosis or ruling out of cancer.

Impact of patient navigation on timely cancer care: the Patient Navigation Research Program

BACKGROUND

Patient navigation is a promising intervention to address cancer disparities but requires a multisite controlled trial to assess its effectiveness.

METHODS

The Patient Navigation Research Program compared patient navigation with usual care on time to diagnosis or treatment for participants with breast, cervical, colorectal, or prostate screening abnormalities and/or cancers between 2007 and 2010. Patient navigators developed individualized strategies to address barriers to care, with the focus on preventing delays in care. To assess timeliness of diagnostic resolution, we conducted a meta-analysis of center- and cancer-specific adjusted hazard ratios (aHRs) comparing patient navigation vs usual care. To assess initiation of cancer therapy, we calculated a single aHR, pooling data across all centers and cancer types. We conducted a metaregression to evaluate variability across centers. All statistical tests were two-sided.

RESULTS

The 10521 participants with abnormal screening tests and 2105 with a cancer or precancer diagnosis were predominantly from racial/ethnic minority groups (73%) and publically insured (40%) or uninsured (31%). There was no benefit during the first 90 days of care, but a benefit of navigation was seen from 91 to 365 days for both diagnostic resolution (aHR = 1.51; 95% confidence interval [CI] = 1.23 to 1.84; P < .001)) and treatment initiation (aHR = 1.43; 95% CI = 1.10 to 1.86; P < .007). Metaregression revealed that navigation had its greatest benefits within centers with the greatest delays in follow-up under usual care.

CONCLUSIONS

Patient navigation demonstrated a moderate benefit in improving timely cancer care. These results support adoption of patient navigation in settings that serve populations at risk of being lost to follow-up.

Breast cancer stage at diagnosis among medically underserved women screened through the Texas Breast and Cervical Cancer Services

The Texas Breast and Cervical Cancer Services (BCCS) program was established to address the socioeconomic disparities in stage at diagnosis and outcomes among breast cancer patients. This study examines the impact of Texas BCCS on stage at diagnosis among low socioeconomic status (SES) breast cancer patients. This is a retrospective analysis of women aged 40-64 years who were screened and diagnosed with breast cancer through the Texas BCCS program (participants) as compared with similar women living in low-SES census tracts and diagnosed outside the program (comparison group) during 1995-2008. Incident cases among the participants were compared with the comparison group as well. Stage at diagnosis was also analyzed separately for the years 1995-2002 and 2003-2008 in order to estimate the effect of BCCS-related Medicaid expansion in 2002. Over the study period of 1995-2008, BCCS participants had a 1.23 (P value<0.0001) times higher odds, and BCCS incident cases had 40% (P value<0.0001) lower odds of advanced stage at diagnosis as compared with the comparison group. A statistically significant difference in stage at diagnosis between the participants and the comparison group only existed for the 2003-2008 (post-Medicaid) period (odds ratio: 1.39, P value<0.0001). Texas BCCS program acts as a source of diagnosis and treatment access to many suspected cancer cases, especially since the 2002 Medicaid expansion, leading to more advanced stage at diagnosis among the BCCS cases as compared with other low-SES cases. Significant expansion of the program to serve a higher proportion of the eligible population is needed to achieve its goals as a screening program.

Percutaneous core biopsy of palpable breast lesions: accuracy of frozen section histopathological exam in the diagnosis of breast cancer

OBJECTIVE

to evaluate the accuracy of frozen section histopathology from fragments of tissue obtained by percutaneous core needle biopsy of palpable tumors in the diagnosis of breast cancer.

METHODS

a cohort study was performed on 57 patients with palpable tumors and suspected breast cancer undergoing percutaneous thick needle core biopsy. The fragments were analyzed by the same pathologist.

RESULTS

frozen section diagnosed 16 benign cases (28.6%) and 40 malignant (71.4%), whereas paraffin showed that 15 were benign (26.8%) and 41 malignant (73.2%). Histopathological examinations were concordant in 55 cases and there was one false-negative (6.2%). Statistics rates were: negative predictive value of 93.8%, positive predictive value of 100%, no false-positive (0%), one false negative (6.2%), specificity of 100%, sensitivity of 97 6%; observed agreement = 98.2%; expected agreement = 59.9%, Kappa = 0.955 [ 95% CI = 0.925-0.974, p < 0.01 ].

CONCLUSIONS

frozen section histopathological findings showed excellent correlation with the findings by the technique in paraffin in the fragments of palpable breast tumors obtained by thick needle percutaneous core biopsy (98.2% accuracy). Therefore, in these patients, it was possible to anticipate the diagnosis, staging and the breast cancer treatment planning.

Clinical and prognostic factors associated with diagnostic wait times by breast cancer detection method

Introduction

Although prognostic differences between screen-detected, interval and symptomatic breast cancers are known, factors associated with wait times to diagnosis among these three groups have not been studied.

Methods

Of the 16,373 invasive breast cancers diagnosed between January 1, 1995 and December 31, 2003 in a cohort of Ontario women aged 50 to 69, a random sample (N = 2,615) were selected for chart abstraction. Eligible women were classified according to detection method; screen-detected (n = 1181), interval (n = 319) or symptomatic (n = 406). Diagnostic wait time was calculated from the initial imaging or biopsy to breast cancer diagnosis. Logistic regression analysis examined associations between diagnostic wait times dichotomized as greater or less than the median and demographic, clinical and prognostic factors separately for each detection cohort.

Results

Women who underwent an open biopsy had significantly longer than median wait times to diagnosis, compared to women who underwent a fine needle aspiration or core biopsy; (screen-detected OR = 2.76, 95% CI = 2.14-3.56; interval OR = 2.56, 95% CI = 1.50-4.35; symptomatic OR = 5.56, 95% CI = 3.33-9.30). Additionally, screen-detected breast cancers diagnosed with stage II and symptomatic cancers diagnosed at stage III or IV had significantly shorter diagnostic wait times compared to those diagnosed at stage 1 (OR = 0.66 95% CI = 0.50-0.87 and OR = 0.46, 95% CI = 0.25-0.85 respectively).

Conclusions

Our study is consistent with expedited diagnostic work-up for breast cancers with more advanced prognostic features. Furthermore, women who had an open surgical biopsy had a greater than the median diagnostic wait time, irrespective of detection method.

Factors influencing time to diagnosis after abnormal mammography in diverse women

BACKGROUND

Abnormal mammograms are common, and the risk of false positives is high. We surveyed women in order to understand the factors influencing the efficiency of the evaluation of an abnormal mammogram.

METHODS

Women aged 40-80 years, identified from lists with Breast Imaging Reporting and Data System (BIRADS) classifications of 0, 3, 4, or 5, were surveyed. Telephone surveys asked about the process of evaluation, and medical records were reviewed for tests and timing of evaluation.

RESULTS

In this study, 970 women were surveyed, and 951 had chart reviews. Overall, 36% were college graduates, 68% were members of a group model health plan, 18% were Latinas, 25% were African Americans, 15% were Asian, and 43% were white. Of the 352 women who underwent biopsies, 151 were diagnosed with cancer (93 invasive). Median time to diagnosis was 183 days for BIRADS 3 compared to 29 days for BIRADS 4/5 and 27 days for BIRADS 0. At 60 days, 84% of BIRADS 4/5 women had a diagnosis. Being African American (hazard ratio [HR] 0.69, 95% confidence interval [CI] 0.49-0.97, p=0.03), income < $10,000 (HR 0.55, 95% CI 0.31-0.98, p<0.04), perceived discrimination (HR 0.22, 95% CI 0.09-0.52, p<0.001), not fully understanding the results of the index mammogram (HR 0.49, 95% CI 0.32-0.75, p=0.001), and being notified by letter (HR 0.66, 95% CI 0.48-0.90, p=0.01) or telephone (HR 0.62, 95% CI 0.42-0.92, p=0.02) rather than in person were all associated with significant delays in diagnosis.

CONCLUSIONS

Evaluation of BIRADS 0, 4, or 5 abnormal mammograms was completed in most women within the recommended 60 days. Even within effective systems, correctible communication factors may adversely affect time to diagnosis.

Effect on survival of longer intervals between confirmed diagnosis and treatment initiation among low-income women with breast cancer

PURPOSE

To determine the impact of longer periods between biopsy-confirmed breast cancer diagnosis and the initiation of treatment (Dx2Tx) on survival.

PATIENTS AND METHODS

This study was a noninterventional, retrospective analysis of adult female North Carolina Medicaid enrollees diagnosed with breast cancer from January 1, 2000, through December, 31, 2002, in the linked North Carolina Central Cancer Registry-Medicaid Claims database. Follow-up data were available through July 31, 2006. Cox proportional hazards regression models were constructed to evaluate the impact on survival of delaying treatment ≥ 60 days after a confirmed diagnosis of breast cancer.

RESULTS

The study cohort consisted of 1,786 low-income, adult women with a mean age of 61.6 years. A large proportion of the patients (44.3%) were racial minorities. Median time from biopsy-confirmed diagnosis to treatment initiation was 22 days. Adjusted Cox proportional hazards regression showed that although Dx2Tx length did not affect survival among those diagnosed at early stage, among late-stage patients, intervals between diagnosis and first treatment ≥ 60 days were associated with significantly worse overall survival (hazard ratio [HR], 1.66; 95% CI, 1.00 to 2.77; P = .05) and breast cancer-specific survival (HR, 1.85; 95% CI, 1.04 to 3.27; P = .04).

CONCLUSION

One in 10 women waited ≥ 60 days to initiate treatment after a diagnosis of breast cancer. Waiting ≥ 60 days to initiate treatment was associated with a significant 66% and 85% increased risk of overall and breast cancer-related death, respectively, among late-stage patients. Interventions designed to increase the timeliness of receiving breast cancer treatments should target late-stage patients, and clinicians should strive to promptly triage and initiate treatment for patients diagnosed at late stage.

Characteristics of women with breast cancer seen at reference services in the North of Minas Gerais

OBJECTIVE

To describe the main characteristics, including stage of disease and local treatment of patients admitted to two reference services for the treatment of breast cancer in the North of Minas Gerais.

METHODS

We conducted a cross-sectional descriptive study. We evaluated medical records of 288 female patients with breast cancer admitted between January 2006 and December 2009, referred from a public hospital and a private clinic. Variables were analyzed using the chi-square test and multinomial logistic regression.

RESULTS

68.1% of patients were referred from the public hospital. There was a predominance of patients over 50 years old (54.5%), married (59%) and with children (87.8%). The mean age of the population studied was 63 years old. Time between suspected cancer and confirmation of diagnosis was over six months in 42.7% of patients. Cancer diagnosis was late (stage III and IV) in 47.6% of patients. Family history of breast cancer was present in 20.1%, 20.8% of them had performed self-breast examination, and 41% had been submitted to a mammogram.

CONCLUSION

There was a higher prevalence of stage III/IV patients from the public service when compared to the private sector. We found that the major factors associated with the late diagnosis of breast cancer were the delay between suspected and confirmed diagnosis, the absence of family history of breast cancer and not having a mammogram.

Improving work-up of the abnormal mammogram through organized assessment: results from the ontario breast screening program

PURPOSE

Women with an abnormal screening mammogram should ideally undergo an organized assessment to attain a timely diagnosis. This study evaluated outcomes of women undergoing work-up after abnormal mammogram through a formal breast assessment affiliate (BAA) program with explicit care pathways compared with usual care (UC) using developed quality indicators for screening mammography programs.

METHODS

Between January 1 and December 31, 2007, a total of 320,635 women underwent a screening mammogram through the Ontario Breast Screening Program (OBSP), of whom 25,543 had an abnormal result requiring further assessment. Established indicators assessing timeliness, appropriateness of follow-up, and biopsy rates were compared between women who were assessed through either a BAA or UC using χ(2) analysis.

RESULTS

Work-up of the abnormal mammogram for patients screened through a BAA resulted in a greater proportion of women attaining a definitive diagnosis within the recommended time interval when a histologic diagnosis was required. In addition, use of other quality measures including specimen radiography for both core biopsies and surgical specimens and preoperative core needle biopsy was greater in BAA facilities.

CONCLUSION

These findings support future efforts to increase the number of BAAs within the OBSP, because the pathways and reporting methods associated with them result in improvements in our ability to provide timely and appropriate care for women requiring work-up of an abnormal mammogram.

The racial disparity in breast cancer mortality

Black women die of breast cancer at a much higher rate than white women. Recent studies have suggested that this racial disparity might be even greater in Chicago than the country as a whole. When data describing this racial disparity are presented they are sometimes attributed in part to racial differences in tumor biology. Vital records data were employed to calculate age-adjusted breast cancer mortality rates for women in Chicago, New York City and the United States from 1980-2005. Race-specific rate ratios were used to measure the disparity in breast cancer mortality. Breast cancer mortality rates by race are the main outcome. In all three geographies the rate ratios were approximately equal in 1980 and stayed that way until the early 1990s, when the white rates started to decline while the black rates remained rather constant. By 2005 the black:white rate ratio was 1.36 in NYC, 1.38 in the US, and 1.98 in Chicago. In any number of ways these data are inconsistent with the notion that the disparity in black:white breast cancer mortality rates is a function of differential biology. Three societal hypotheses are posited that may explain this disparity. All three are actionable, beginning today.