Prognostic implications of emergency admission and delays in patients with breast cancer

Comparison of oncological care in a hospital center before and after the integration of specialized oncology services

BACKGROUND

Cancer represents a continuous challenge for global public health, with steadily increasing incidence and mortality rates.

METHODS

This manuscript presents a comprehensive and retrospective analysis of oncological care in a hospital, evaluating quality indicators after the introduction of a specialized oncology service at the center. Initially, it was implemented partially and then fully, allowing for the comparison of three different periods: without service, with partial service, and with full service. The data used was obtained from the TumorRegistry of the Costa del Sol Hospital (HTRCSH).

RESULTS

Throughout this study, significant improvements were identified in various indicators, such as a reduction in the percentage of patients admitted through the emergency service (p=0.001), the percentage of primary cancers of unknown origin (p=0.006), and the percentage of cancers with regional extension (p=0.004). Additionally, there was a notable increase in the percentage of inclusion of the complete tumor stage information in the patient's medical record (p=0.004), the percentage of patients receiving adjuvant treatment (p=0.001), and the percentage of patients with an intention for radical treatment (p=0.007).

CONCLUSIONS

These results underscore the importance of oncology services in improving care for cancer patients. Despite the limitations, our study highlights important areas for future research, which will be addressed through additional data collection and more detailed analyses.

Breast Cancer Treatment Delay in SafetyNet Health Systems, Houston Versus Southeast Brazil

Background

Breast cancer outcomes among patients who use safety-net hospitals in the highly populated Harris County, Texas and Southeast Brazil are poor. It is unknown whether treatment delay contributes to these outcomes.

Methods

We conducted a retrospective cohort analysis of patients with non-metastatic breast cancer diagnosed between January 1, 2009 and December 31, 2011 at Harris Health Texas and Unicamp’s Women’s Hospital, Barretos Hospital, and Brazilian National Institute of Cancer, Brazil. We used Cox proportional hazards regression to evaluate association of time to treatment and risk of recurrence (ROR) or death.

Results

One thousand one hundred ninety-one patients were included. Women in Brazil were more frequently diagnosed with stage III disease (32.3% vs. 21.1% Texas; P = .002). Majority of patients in both populations had symptom-detected disease (63% in Brazil vs. 59% in Texas). Recurrence within 5 years from diagnosis was similar 21% versus 23%. Median time from diagnosis to first treatment defined as either systemic therapy (chemotherapy or endocrine therapy) or surgery, were comparable, 9.9 weeks versus 9.4 weeks. Treatment delay was not associated with increased ROR or death. Higher stage at diagnosis was associated with both increased ROR and death.

Conclusion

Time from symptoms to treatment was considerably long in both populations. Treatment delay did not affect outcomes.

Impact

Access to timely screening and diagnosis of breast cancer are priorities in these populations.

Influence of Diagnostic Delay on Survival Rates for Patients with Colorectal Cancer

Colorectal cancer affects men and women alike. Sometimes, due to clinical-pathological factors, the absence of symptoms or the failure to conduct screening tests, its diagnosis may be delayed. However, it has not been conclusively shown that such a delay, especially when attributable to the health system, affects survival. The aim of the present study is to evaluate the overall survival rate of patients with a delayed diagnosis of colorectal cancer. This observational, prospective, multicenter study was conducted at 22 public hospitals located in nine Spanish provinces. For this analysis, 1688 patients with complete information in essential variables were included. The association between diagnostic delay and overall survival at five years, stratified according to tumor location, was estimated by the Kaplan-Meier method. Hazard ratios for this association were estimated using multivariable Cox regression models. The diagnostic delay ≥ 30 days was presented in 944 patients. The presence of a diagnostic delay of more than 30 days was not associated with a worse prognosis, contrary to a delay of less than 30 days (HR: 0.76, 0.64-0.90). In the multivariate analysis, a short delay maintained its predictive value (HR: 0.80, 0.66-0.98) regardless of age, BMI, Charlson index or TNM stage. A diagnostic delay of less than 30 days is an independent factor for short survival in patients with CRC. This association may arise because the clinical management of tumors with severe clinical characteristics and with a poorer prognosis are generally conducted more quickly.

Factors that Influence Treatment Delay for Patients with Breast Cancer

INTRODUCTION

The diagnosis or treatment of breast cancer is sometimes delayed. A lengthy delay may have a negative psychological impact on patients. The aim of our study was to evaluate the sociodemographic, clinical and pathological factors associated with delay in the provision of surgical treatment for localised breast cancer, in a prospective cohort of patients.

METHODS

This observational, prospective, multicentre study was conducted in ten hospitals belonging to the Spanish national public health system, located in four Autonomous Communities (regions). The study included 1236 patients, diagnosed through a screening programme or found to be symptomatic, between April 2013 and May 2015. The study variables analysed included each patient's personal history, care situation, tumour history and data on the surgical intervention, pathological anatomy, hospital admission and follow-up. Treatment delay was defined as more than 30 days elapsed between biopsy and surgery.

RESULTS

Over half of the study population experienced surgical treatment delay. This delay was greater for patients with no formal education and among widows, persons not requiring assistance for usual activities, those experiencing anxiety or depression, those who had a high BMI or an above-average number of comorbidities, those who were symptomatic, who did not receive NMR spectroscopy, who presented a histology other than infiltrating ductal carcinoma or who had poorly differentiated carcinomas.

CONCLUSIONS

Certain sociodemographic and clinical variables are associated with surgical treatment delay. This study identifies factors that influence surgical delays, highlighting the importance of preventing these factors and of raising awareness among the population at risk and among health personnel.

Factors associated with late-stage diagnosis of breast cancer among women in Addis Ababa, Ethiopia

PURPOSE

Stage at diagnosis is a key determinant of breast cancer prognosis. In this study, we characterize stage at diagnosis and determine factors associated with advanced stage at diagnosis among women diagnosed with invasive breast cancer in Addis Ababa, capital city of Ethiopia.

METHODS

Stage information was collected from medical records of 441 women with invasive breast cancer seen in seven major health facilities in Addis Ababa, from January 2017 to June 2018; these seven facilities capture 90% of all incident breast cancer cases in the city. We used multivariable Poisson regression model with robust variance to determine factors associated with advanced stage at diagnosis.

RESULTS

The predominant tumor histology was ductal carcinoma (83.7%). More than half of the tumors' grade was moderately or poorly differentiated. The median tumor size at presentation was 4 cm. Sixty-four percent of the patients were diagnosed at advanced stage of the disease (44% stage III and 20% stage IV), with 36% of the patients diagnosed at early-stage (5% stage I and 31% stage II). The prevalence of advanced stage disease was significantly higher among women who used traditional medicine before diagnostic confirmation (adjusted prevalence ratio [aPR] = 1.31; p = 0.001), had patient delay of >  3 months (aPR = 1.16; p = 0.042) and diagnosis delay of > 2 months (aPR = 1.24; p = 0.004). But it was lower among women who had history of breast self-examination (aPR = 0.77; p = 0.021).

CONCLUSIONS

Advanced stage at diagnosis of breast cancer among women in Addis Ababa is strongly associated with use of traditional medicine and with prolonged time interval between symptom recognition and disease confirmation. Community- and health systems-level interventions are needed to enhance knowledge about breast cancer and facilitate timely diagnoses.

Provider delay in treatment initiation and its influence on survival outcomes in women with operable breast cancer

Aim

The goal of this study was to determine whether a delay in starting treatment via surgery or neoadjuvant chemotherapy is related to a decrease in cancer-specific survival (CSS) in women with operable breast cancer (BrCr).

Background

Limited medical infrastructure and a lack of cancer prevention awareness in low- and middle-income countries have caused high BrCr incidence and mortality rates.

Methods

We analyzed a retrospective cohort of 720 women treated at a single center from 2005 to 2012. CSS estimates were obtained by the Kaplan-Meier method. A Cox model of proportional risks was performed to obtain the risk of dying from BrCr. We also obtained the risk according to the category of treatment initiation.

Results

Women with locally advanced stages and without hormone receptor expression were more likely to initiate treatment after 45 days. Patients in Stage IIIA had a 78.1% survival if treatment was initiated before 45 days (95% CI, 0.70-0.84) and 63.6% survival if treatment was started after 45 days (95% CI, 0.44-0.78; p < 0.001). Patients in Stage IIIB had a 62.9% survival if treatment was initiated before 45 days (95% CI, 0.53-0.72) and 57.4% survival if treatment started after 45 days (95% CI, 0.31-0.89; p < 0.001). Prognostic factors in which lower survival was recognized were Stage IIIA, Stage IIIB, treatment initiation after 45 days, and triple-negative tumors.

Conclusions

The initiation of treatment within the first 45 days of diagnosis of BrCr in women portends better survival compared with those who began treatment longer than 45 days from diagnosis.

First hospital contact via the Emergency Department is an independent predictor of overall survival and disease-free survival in patients with colorectal cancer

AIMS

the aim of this study was to examine the possible association between the type of hospital admission and subsequent survival of the patient, as well as the pathological features recorded in a large population of patients with colorectal cancer.

METHODS

the study included 1,079 patients diagnosed with colon or rectal cancer in the Hospital Costa del Sol (Marbella, Spain). The relationship between patient survival rate and type of first admission to the hospital (elective or emergency admission) was assessed. The following variables were studied: age, gender, tumor location, pathological stage, differentiation grade, chemotherapy before surgery and survival.

RESULTS

colon tumors are more common in patients admitted to hospital for the first time via the emergency service (63.7%) and the tumors tend to be poorly differentiated (64.2%) and metastatic (70%). These patients also present a more aggressive disease and a poorer prognosis than patients with an elective admission. With regard to patients from the Emergency Department, a Cox regression analysis showed a risk-ratio (RR) of 1.36 (confidence interval [CI] 95%: 1.11-1.66) for disease-free survival and of 1.41 (95% CI: 1.14-1.76) for overall survival.

CONCLUSIONS

hospital admission via the Emergency Department is an indicator of aggressiveness and poorer prognosis compared to patients who enter via programmed routes.

Factors Associated with Prolonged Patient-Attributable Delay in the Diagnosis of Colorectal Cancer

Purpose

The delayed diagnosis of colorectal cancer (CRC) may be attributable to sociodemographic characteristics, to aspects of tumour histopathology or to the functioning of the health system. We seek to determine which of these factors most influences prolonged patient-attributable delay (PPAD) in the diagnosis and treatment of CRC.

Materials and Methods

A prospective, multicentre observational study was conducted in 22 Spanish hospitals. In total, 1,785 patients were recruited to the study between 2010 and 2012 and underwent elective or urgent surgery. PPAD is considered to occur when the time elapsed between a patient presenting the symptom and him/her seeking attention from the primary care physician or hospital emergency department exceeds 180 days. A bivariate analysis was performed to assess differences in variables segmented by tumour location and patient delay. Multivariate logistic regression analysis was performed on the outcome variable, PPAD.

Results

The rate of PPAD among this population was 12.1%. PPAD was significantly associated with altered bowel rhythm (odds ratio [OR], 1.36; 95% confidence interval [CI], 1.02 to 1.83) and with adenocarcinoma histology, in comparison with mucinous adenocarcinoma (OR, 2.03; 95% CI, 1.11 to 3.71). Other sociocultural factors and clinicopathological features were not independent predictors of PPAD.

Conclusion

Many patients do not consider altered bowel rhythm an alarming symptom, warranting a visit to the doctor. PPAD could be reduced by improving health education, raising awareness of CRC-related symptoms.

Typical and atypical presenting symptoms of breast cancer and their associations with diagnostic intervals: Evidence from a national audit of cancer diagnosis

INTRODUCTION

Most symptomatic women with breast cancer have relatively short diagnostic intervals but a substantial minority experience prolonged journeys to diagnosis. Atypical presentations (with symptoms other than breast lump) may be responsible.

METHODS

We examined the presenting symptoms of breast cancer in women using data from a national audit initiative (n=2316). Symptoms were categorised topographically. We investigated variation in the length of the patient interval (time from symptom onset to presentation) and the primary care interval (time from presentation to specialist referral) across symptom groups using descriptive analyses and quantile regression.

RESULTS

A total of 56 presenting symptoms were described: breast lump was the most frequent (83%) followed by non-lump breast symptoms, (e.g. nipple abnormalities (7%) and breast pain (6%)); and non-breast symptoms (e.g. back pain (1%) and weight loss (0.3%)). Greater proportions of women with 'non-lump only' and 'both lump and non-lump' symptoms waited 90days or longer before seeking help compared to those with 'breast lump only' (15% and 20% vs. 7% respectively). Quantile regression indicated that the differences in the patient interval persisted after adjusting for age and ethnicity, but there was little variation in primary care interval for the majority of women.

CONCLUSIONS

About 1 in 6 women with breast cancer present with a large spectrum of symptoms other than breast lump. Women who present with non-lump breast symptoms tend to delay seeking help. Further emphasis of breast symptoms other than breast lump in symptom awareness campaigns is warranted.

Factors that influence treatment delay in patients with colorectal cancer

A prospective study was performed of patients diagnosed with colorectal cancer (CRC), distinguishing between colonic and rectal location, to determine the factors that may provoke a delay in the first treatment (DFT) provided.2749 patients diagnosed with CRC were studied. The study population was recruited between June 2010 and December 2012. DFT is defined as time elapsed between diagnosis and first treatment exceeding 30 days.Excessive treatment delay was recorded in 65.5% of the cases, and was more prevalent among rectal cancer patients. Independent predictor variables of DFT in colon cancer patients were a low level of education, small tumour, ex-smoker, asymptomatic at diagnosis and following the application of screening. Among rectal cancer patients, the corresponding factors were primary school education and being asymptomatic.We conclude that treatment delay in CRC patients is affected not only by clinicopathological factors, but also by sociocultural ones. Greater attention should be paid by the healthcare provider to social groups with less formal education, in order to optimise treatment attention.

Identifying predictors of delayed diagnoses in symptomatic breast cancer: a scoping review

Delayed diagnosis of breast cancer can adversely impact patient outcomes. To better understand this issue, we conducted a scoping review of literature from 1996 to 2015 that examined predictors of delayed presentation and diagnosis among women with breast cancer symptoms. We performed searches to identify studies of predictors of the time from symptom onset to first presentation (the patient interval), first presentation to diagnosis (the diagnostic interval) and symptom onset to diagnosis (the total interval) among women with breast cancer symptoms. Two reviewers independently reviewed and abstracted the findings of these studies. Of the 22 studies included in this review, 16 examined predictors of the patient interval, six examined predictors of the diagnostic interval and four examined predictors of the total interval. A total of 116 predictors were examined; three had evidence of an association with a less timely diagnosis: not disclosing symptoms to others, non-lump breast symptoms and African American ethnicity. Improving awareness of atypical breast cancer symptoms and encouraging disclosure could improve the timeliness of a breast cancer diagnosis. Access concerns for vulnerable groups need to be addressed. Future research should be more purposeful in its choice of predictors, possibly through the use of established conceptual frameworks.

Delay in Presentation, Diagnosis and Treatment for Colorectal Cancer Patients in Jordan

PURPOSE

Colorectal cancer (CRC) ranked first among cancers reported in males and second among cancers reported in females in Jordan in 2010. There has been no specific CRC-control programme in Jordan. Additionally, there has been no published study from Jordan or its neighbours on patient delays in presentation, diagnosis or treatment. Therefore, we conducted this study to assess these important quality indicators aiming to improve prognosis for CRC and to provide baseline data for future health promotion programmes for CRC in Jordan.

METHODS

This project was a cross-sectional study on CRC patients at Al Bashir Hospital, Ministry of Health, and at the Military Oncology Centre of the Jordanian Royal Medical Services.

RESULTS

The total number of participants was 189. The proportion of patients with presentation delay, diagnosis delay or treatment delay was 33.9, 68.1 and 32.6%, respectively. The main reasons reported for delay in presentation were lack of knowledge that symptoms were suggestive of cancer (58.5%), misdiagnosis by physicians or pharmacists (38.4%) or the patient did not want to visit a doctor (3.1%). Predictors of delay and mean time for presentation, diagnosis and treatment were identified.

CONCLUSIONS

Our results revealed that CRC patients in Jordan experience delays in presentation, Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation diagnosis, and, to a lesser degree, in treatment. This could justify the advanced stages at diagnosis and poor outcomes for CRC patients. Our findings provide baseline information for future CRC-control programmes in Jordan. We recommend that CRC prevention programmes in Jordan focus on early detection of CRC and target both patients and physicians.

The Impact of Rurality and Disadvantage on the Diagnostic Interval for Breast Cancer in a Large Population-Based Study of 3202 Women in Queensland, Australia

Delays in diagnosing breast cancer (BC) can lead to poorer outcomes. We investigated factors related to the diagnostic interval in a population-based cohort of 3202 women diagnosed with BC in Queensland, Australia. Interviews ascertained method of detection and dates of medical/procedural appointments, and clinical information was obtained from medical records. Time intervals were calculated from self-recognition of symptoms (symptom-detected) or mammogram (screen-detected) to diagnosis (diagnostic interval (DI)). The cohort included 1560 women with symptom-detected and 1642 with screen-detected BC. Symptom-detected women had higher odds of DI of >60 days if they were Indigenous (OR = 3.12, 95% CI = 1.40, 6.98); lived in outer regional (OR = 1.50, 95% CI = 1.09, 2.06) or remote locations (OR = 2.46, 95% CI = 1.39, 4.38); or presented with a "non-lump" symptom (OR = 1.84, 95% CI = 1.43, 2.36). For screen-detected BC, women who were Indigenous (OR = 2.36, 95% CI = 1.03, 5.80); lived in remote locations (OR = 2.35, 95% CI = 1.24, 4.44); or disadvantaged areas (OR = 1.69, 95% CI = 1.17, 2.43) and attended a public screening facility (OR = 2.10, 95% CI = 1.40, 3.17) had higher odds of DI > 30 days. Our study indicates a disadvantage in terms of DI for rural, disadvantaged and Indigenous women. Difficulties in accessing primary care and diagnostic services are evident. There is a need to identify and implement an efficient and effective model of care to minimize avoidable longer diagnostic intervals.

Delay in Presentation, Diagnosis, and Treatment for Breast Cancer Patients in Jordan

Breast cancer is the most common cancer, and one of the leading causes of death for females in Jordan and many countries in the world. Studies have shown that delay in symptoms presentation, diagnosis or treatment would result in poor prognosis. There has been no published study from Jordan on delays in patient presentation, delays in diagnosis, or delays in treatment. Therefore, we conducted this study to assess these important quality indicators aiming to improve prognosis for breast cancer patients in Jordan. This project was a cross-sectional study on female breast cancer patients in Jordan. The total number of participants was 327. The proportion of patients with presentation delay, diagnosis delay, and treatment delay was 32.2%, 49.1%, or 32.4%, respectively. The main reported reasons for delay in presentation were ignorance of the nature of the problem (65.6%), limited/lack of knowledge that symptoms were suggestive of cancer diagnosis (16.7%), and misdiagnosis (16.7%). Predictors of delay and mean time for presentation, diagnosis, and treatment were identified. Our results reveal that breast cancer patients in Jordan are experiencing delays in presentation, diagnosis, and treatment. This could justify the advanced stages at diagnosis and poor outcomes for breast cancer patients in Jordan. We recommend revising the current early detection and down-staging programs in Jordan.

Early postoperative emergency department presentation predicts poor long-term outcomes in patients surgically treated for meningioma

Previous authors have identified a number of factors that predict morbidity, mortality, and recurrence in patients undergoing resection of a meningioma. We sought to study a novel potential prognostic indicator: early postoperative visit to the emergency department (ED). We conducted a retrospective cohort study on 239 patients who underwent a meningioma resection at our institution between 2001 and 2013 with over 3 months of follow-up postoperatively. All postoperative entries in the medical record were reviewed to identify any ED visit with a neurologic or wound-related complaint within a 90 day postoperative period. The relationships between ED presentation, tumor grade, and extent of surgical resection with future risk of operative recurrence and mortality were analyzed using Fisher's exact test. Variables associated with increased risks of mortality or operative recurrence in a univariate analysis were then included in the multivariate logistic regression model. Patients with a postoperative ED visit were found to be significantly more likely to die during the follow-up period (23.0% versus 4.85%, p<0.0001) or develop an eventual operative recurrence (12.2% versus 3.0%, p=0.0131). Postoperative ED presentation was found to be associated with a higher risk of mortality and operative recurrence independent of pathological tumor grade (p<0.0001 and p=0.0102, respectively). Presentation to the ED is associated with significantly higher rates of future operative recurrence and mortality in patients with recent meningioma resections. This poor prognostic relationship is independent of tumor pathological grade. Increased vigilance and follow-up may be warranted in such patients.

Private Payer's Status Improves Male Breast Cancer Survival

Survival from male breast cancer is influenced by many factors. This study assessed payer's status effect on survival of male breast cancer patients. This study included 8,828 male breast cancer patients diagnosed between 1998-2006 and followed to 2011 in the National Cancer Data Base. Cox regression was used to investigate the effect of payer's status and other factors on overall survival. Patients had 36.2%, 42.7%, 14.7%, and 6.5% of stage I to IV cancer, respectively. Payer status was private 47.7%, Medicare 42.6%, Medicaid 3.24%, unknown 3.59%, and uninsured 2.95%. Median overall survival (MOS) for all patients was 10.6 years. In multivariate analysis, Direct adjusted MOS was 12.46, 11.89, 9.99, 9.02, and 8.29 years for private, "unknown," Medicare, uninsured, and Medicaid payer's status, respectively. Patients with private and "unknown" payer's status showed a significant difference in survival compared to uninsured patients, while Medicaid and Medicare patients did not. Age, race, stage, grade, income, comorbidity, distance travelled, and diagnosing/treating facility were also significant predictors of survival. Treatment delay and cancer program did not have a significant influence on survival.

Effects of payer status on breast cancer survival: a retrospective study

Background

Breast cancer outcomes are influenced by multiple factors including access to care, and payer status is a recognized barrier to treatment access. To further define the influence of payer status on outcome, the National Cancer Data Base data from 1998–2006 was analyzed.

Method

Data was analyzed from 976,178 female patients diagnosed with breast cancer registered in the National Cancer Data Base. Overall survival was the primary outcome variable while payer status was the primary predictor variable. Secondary predictor variables included stage, age, race, Charlson Comorbidity index, income, education, distance travelled, cancer program, diagnosing/treating facility, and treatment delay. Multivariate Cox regression was used to investigate the effect of payer status on overall survival while adjusting for secondary predictive factors.

Results

Uninsured (28.68%) and Medicaid (28.0%) patients had a higher percentage of patients presenting with stage III and stage IV cancer at diagnosis. In multivariate analysis, after adjusting for secondary predictor variables, payer status was a statistically significant predictor of survival. Patients with private, unknown, or Medicare status showed a decreased risk of dying compared to uninsured, with a decrease of 36%, 22%, and 15% respectively. However, Medicaid patients had an increased risk of 11% compared to uninsured. The direct adjusted median overall survival was 14.92, 14.76, 14.56, 13.64, and 12.84 years for payer status of private, unknown, Medicare, uninsured, and Medicaid respectively.

Conclusion

We observed that patients with no insurance or Medicaid were most likely to be diagnosed at stage III and IV. Payer status showed a statistically significant relationship with overall survival. This remained true after adjusting for other predictive factors. Patients with no insurance or Medicaid had higher mortality.

Delay in breast cancer: implications for stage at diagnosis and survival

Breast cancer continues to be a disease with tremendous public health significance. Primary prevention of breast cancer is still not available, so efforts to promote early detection continue to be the major focus in fighting breast cancer. Since early detection is associated with decreased mortality, one would think that it is important to minimize delays in detection and diagnosis. There are two major types of delay. Patient delay is delay in seeking medical attention after self-discovering a potential breast cancer symptom. System delay is delay within the health care system in getting appointments, scheduling diagnostic tests, receiving a definitive diagnosis, and initiating therapy. Earlier studies of the consequences of delay on prognosis tended to show that increased delay is associated with more advanced stage cancers at diagnosis, thus resulting in poorer chances for survival. More recent studies have had mixed results, with some studies showing increased survival with longer delays. One hypothesis is that diagnostic difficulties could perhaps account for this survival paradox. A rapidly growing lump may suggest cancer to both doctors and patients, while a slow growing lump or other symptoms could be less obvious to them. If this is the case, then the shorter delays would be seen with the more aggressive tumors for which the prognosis is worse leading to reduced survival. It seems logical that a tumor that is more advanced at diagnosis would lead to shorter survival but the several counter-intuitive studies in this review show that it is dangerous to make assumptions.

Detection methods predict differences in biology and survival in breast cancer patients

BACKGROUND

The aim of this study was to measure the biological characteristics involved in tumorigenesis and the progression of breast cancer in symptomatic and screen-detected carcinomas to identify possible differences.

METHODS

For this purpose, we evaluated clinical-pathological parameters and proliferative and apoptotic activities in a series of 130 symptomatic and 161 screen-detected tumors.

RESULTS

After adjustment for the smaller size of the screen-detected carcinomas compared with symptomatic cancers, those detected in the screening program presented longer disease-free survival (RR = 0.43, CI = 0.19-0.96) and had high estrogen and progesterone receptor concentrations more often than did symptomatic cancers (OR = 3.38, CI = 1.72-6.63 and OR = 3.44, CI = 1.94-6.10, respectively). Furthermore, the expression of bcl-2, a marker of good prognosis in breast cancer, was higher and HER2/neu expression was lower in screen-detected cancers than in symptomatic cancers (OR = 1.77, CI = 1.01-3.23 and OR = 0.64, CI = 0.40-0.98, respectively). However, when comparing prevalent vs incident screen-detected carcinomas, prevalent tumors were larger (OR = 2.84, CI = 1.05-7.69), were less likely to be HER2/neu positive (OR = 0.22, CI = 0.08-0.61) and presented lower Ki67 expression (OR = 0.36, CI = 0.17-0.77). In addition, incident tumors presented a shorter survival time than did prevalent ones (RR = 4.88, CI = 1.12-21.19).

CONCLUSIONS

Incident carcinomas include a variety of screen-detected carcinomas that exhibit differences in biology and prognosis relative to prevalent carcinomas. The detection method is important and should be taken into account when making therapy decisions.

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.

The "two-week wait" referral pathway allows prompt treatment but does not improve outcome for patients with oesophago-gastric cancer

INTRODUCTION

The Two Week Wait Referral Service (2WW) has been implemented as a means of fast-tracking patients with suspected upper gastrointestinal cancers for endoscopy. Whether or not it impacts on the outcome of these patients is unclear. The aim of this study was to compare the outcome of patients referred through 2WW with that of patients with oesophago-gastric cancer identified through alternate referral pathways (routine, emergency).

METHODS

The study population was 340 patients with oesophago-gastric carcinoma (gastric 154) diagnosed during the time period 01/2006-12/2007 at University Hospitals of Leicester NHS Trust. Data were collected prospectively by the MDT co-ordinator and analysed retrospectively.

RESULTS

135 of the 340 patients with oesophago-gastric cancer were diagnosed through the 2WW, 115 patients through routine referral pathways, and 90 patients were admitted on an emergency basis. Patients referred through 2WW had a median referral to 1st treatment time of 47 days (routine 79, emergency 28, p < 0.001 all group comparisons). The number of patients treated with potentially curative intent was 37 of 135 for the 2WW, 42 of 115 for the routine referrals and 10 of 90 for patients admitted as emergencies. The corresponding median survivals for the groups were 239 days (2WW), 405 days (routine) and 121 days (emergency), p < 0.001 (log rank).

CONCLUSIONS

Referral by 2WW resulted in more rapid treatment than routine referral but this did not translate into an improvement in survival. This suggests that the targeting of endoscopy to patients with alarm symptoms is flawed and a less selective approach should be promoted if curable cancers are to be detected.