The relationship between time to initiation of adjuvant chemotherapy and survival in breast cancer: a systematic review and meta-analysis

Impact of neoadjuvant compared to adjuvant chemotherapy on prognosis in patients with hormone-receptor positive / HER2-negative breast cancer: A propensity score matching population-based study

BACKGROUND

The aim of this population-based cohort study was to investigate the impact of neoadjuvant chemotherapy (NACT) compared to adjuvant chemotherapy in prognosis among patients with HR+/HER2 negative breast cancer.

METHOD

This population-based study utilized data from the research database BCBaSe 3.0, based on the Swedish National Quality breast cancer register, including all patients with breast cancer diagnosis in Sweden between 2008 and 2019. Propensity score matching approach was applied. The outcomes of interest consisted of distant-disease free (DDFS), breast-cancer specific (BCSS), and overall survival (OS).

RESULTS

In total, 14 459 patients were included in the study cohort of whom 2086 received NACT. After 1:1 propensity score matching (PSM), 1539 patients in each study group were available for analyses. No statistically significant difference in survival outcomes were observed between patients treated with NACT compared to those treated with adjuvant chemotherapy (Hazard Ratio (HR) for DDFS: 1.20; 95 % CI: 0.80-1.79; HR for BCSS: 1.16; 95 % CI: 0.54-2.49; HR for OS: 1.14; 95 % CI: 0.64-2.05).

CONCLUSION

In this population-based cohort study of patients with HR+/HER2-breast cancer, the use of NACT seems to be comparable to adjuvant chemotherapy in terms of prognosis, although non-inferiority cannot be proven by this study design. Until further evidence suggesting a survival benefit in favor of either treatment is available, NACT can be pursued when surgical-de-escalation is intended.

Individual and area level factors associated with the breast cancer diagnostic-treatment interval in Queensland, Australia

BACKGROUND

Delays to breast cancer treatment can lead to more aggressive and extensive treatments, increased expenses, increased psychological distress, and poorer survival. We explored the individual and area level factors associated with the interval between diagnosis and first treatment in a population-based cohort in Queensland, Australia.

METHODS

Data from 3216 Queensland women aged 20 to 79, diagnosed with invasive breast cancer (ICD-O-3 C50) between March 2010 and June 2013 were analysed. Diagnostic dates were sourced from the Queensland Cancer Registry and treatment dates were collected via self-report. Diagnostics-treatment intervals were modelled using flexible parametric survival methods.

RESULTS

The median interval between breast cancer diagnosis and first treatment was 15 days, with an interquartile range of 9-26 days. Longer diagnostic-treatment intervals were associated with a lack of private health coverage, lower pre-diagnostic income, first treatments other than breast conserving surgery, and residence outside a major city. The model explained a modest 13.7% of the variance in the diagnostic-treatment interval [Formula: see text]. Sauerbrei's D was 0.82, demonstrating low to moderate discrimination performance.

CONCLUSION

Whilst this study identified several individual- and area-level factors associated with the time between breast cancer diagnosis and first treatment, much of the variation remained unexplained. Increased socioeconomic disadvantage appears to predict longer diagnostic-treatment intervals. Though some of the differences are small, many of the same factors have also been linked to screening and diagnostic delay. Given the potential for accumulation of delay at multiple stages along the diagnostic and treatment pathway, identifying and applying effective strategies address barriers to timely health care faced by socioeconomically disadvantaged women remains a priority.

Contralateral prophylactic mastectomy: Weighing the risks of delayed chemotherapy, radiotherapy, and hormonal therapy

BACKGROUND

Many patients with unilateral breast cancer opt for contralateral prophylactic mastectomy (CPM) at the time of therapeutic mastectomy (immediate CPM) or following completion of adjuvant therapy. Studies show that immediate CPM increases the risk of surgical complications related to unilateral mastectomy (UM) alone, which may lead to delays in adjuvant therapy initiation. However, it is unclear if these complications cause clinically significant delays in initiating adjuvant chemotherapy, radiotherapy, or hormonal therapy.

METHODS

A retrospective chart review was conducted on patients with breast cancer who underwent immediate CPM versus UM alone at Columbia University Medical Center from January 2000 to December 2020. Patient demographic and oncologic characteristics; complications; and timing of adjuvant chemotherapy, radiotherapy, and/or hormonal therapy relative to therapeutic mastectomy were collected.

RESULTS

In this study, 239 UM alone patients were propensity score matched to 239 immediate CPM patients. No significant difference in complication rates was found between the index and contralateral breasts in CPM patients. A similar percentage of CPM and UM patients experienced postoperative complications (19% vs. 17%, p = 0.64). No significant difference in time to adjuvant chemotherapy, radiotherapy, or hormonal therapy was found between CPM patients with complications and all CPM patients or all UM patients.

CONCLUSIONS

There is a lack of clear guidance for clinical decision-making regarding timing of CPM relative to adjuvant therapy. Our study suggests that immediate CPM does not significantly increase the risks of postoperative complications or complication-related delays in the initiation of adjuvant chemotherapy, radiotherapy, or hormonal therapy. This information may help patients and providers to plan, select, and schedule breast cancer treatment options.

Oncoplastic Breast Reconstruction in Morbidly Obese Patients: An Acceptable Practice

Background

Breast cancer is the most common noncutaneous malignancy amongst women. Lumpectomy with adjuvant radiation is a mainstay of surgical treatment. Oncoplastic breast reconstruction reduces the resultant breast deformity. Obesity is a risk factor for the development of complications after breast reconstruction. This study's purpose was to determine if oncoplastic breast reconstruction is a safe procedure in obese patients.

Methods

A single institution retrospective chart review was performed on women undergoing oncoplastic breast reduction from 2009 to 2021. Patients were then divided into groups based on body mass index (BMI). A statistical analysis was performed comparing rates of complications and time to adjuvant therapy.

Results

An estimated 340 patients were identified with an average age of 56.2 years (140 with BMI <30 kg/m2, 87 with BMI 30-34.9 kg/m2, 62 with BMI 35-39.9 kg/m2, and 51 with BMI >40 kg/m2). There was a significant difference between the BMI greater than 40 kg per m2 and BMI less than 30 kg per m2 group in the number of returns to the operating room (P = 0.0096), major complications (P = 0.0002), and minor complications (P = 0.0051). Average time to adjuvant treatment was 47 days and there was no statistically significant difference between the groups (P = 0.1691).

Conclusions

There was a significant difference in major and minor complications between the BMI groups; however, there was no delay in the time to adjuvant therapy. Therefore, we conclude that with appropriate counseling on surgical risks, oncoplastic breast reduction is an acceptable option for breast cancer patients after lumpectomy, regardless of BMI.

Head and Neck Cancer Patient Population, Management, and Oncologic Outcomes from the COVID-19 Pandemic

The COVID-19 pandemic precipitated drastic changes in cancer care. Its impact on the U.S. head and neck cancer population has yet to be fully understood. This study aims to understand the impact of pandemic-related changes on the head and neck cancer population. An observational study of head and neck cancer patients at a single institution during the spring of 2020 and 2019 was performed. Clinical characteristics and survival outcomes were analyzed. In 2020, 54 head and neck cancer patients were evaluated in the department of radiation oncology vs. 74 patients seen in 2019; 42% of the patients were female in 2019 versus 24% in 2020 (p = 0.036). The median follow-up time was 19.4 and 31 months for 2020 and 2019, respectively. After adjusting for stage, the relapse-free survival probability at 6 and 12 months was 79% and 69% in 2020 vs. 96% and 89% in 2019, respectively (p = 0.036). There was no significant difference in the overall survival, with 94% and 89% in 2020 and 2019, respectively (p = 0.61). Twenty-one percent of patients received induction chemotherapy in 2020 versus 5% in 2019 (p = 0.011); significantly more treatment incompletions occurred in 2020, 9% vs. 0% in 2019 (p = 0.012). Moreover, the stage-adjusted RFS differed between cohorts, suggesting head and neck cancer patients seen during the initial wave of COVID-19 may experience worse oncologic outcomes.

Anatomic Location of Tissue Expander Placement Is Not Associated With Delay in Adjuvant Therapy in Women With Breast Cancer

BACKGROUND

Tissue expanders in breast reconstruction are traditionally placed retropectoral. Increasingly, patients are undergoing prepectoral placement. The impact of this placement on the initiation of adjuvant treatment is unknown.

METHODS

A retrospective review was conducted to identify women diagnosed with breast cancer who underwent mastectomy followed by radiation and/or chemotherapy. Women were divided into 3 groups: prepectoral tissue expander placement, retropectoral tissue expander placement, and no immediate reconstruction. A treatment delay was defined as greater than 8 weeks between tissue expander placement and adjuvant therapy.

RESULTS

Of 634 women, 205 (32%) underwent tissue expander placement, and 429 (68%) did not have immediate reconstruction. Of those with tissue expanders placed, 84 (41%) had prepectoral placement, and 121 (59%) had retropectoral placement. The median time to adjuvant therapy was 49 days for the entire cohort: no reconstruction, 47 days; prepectoral, 57 days; and retropectoral, 55 days. Treatment delays were observed in 34% of women: no reconstruction, 28%; prepectoral, 51%; and retropectoral, 46% ( P < 0.001). Tissue expander placement was associated with a delay to adjuvant therapy when compared with no reconstruction ( P < 0.001). The location of the tissue expander did not impact the odds of having a delay. On multivariable analysis, having reconstruction, having postoperative infection, not undergoing chemotherapy treatment, and being a current smoker were associated with a delay to adjuvant therapy. A delay to treatment was not associated with worse survival.

CONCLUSIONS

Placement of a tissue expander delayed adjuvant therapy. The location of tissue expander placement, retropectoral versus prepectoral, did not impact the time to adjuvant treatment.

Timeliness of Multimodal Care for At-Risk Breast Cancer Patients at a Safety Net Institution

INTRODUCTION

Because limited data exist, we sought to evaluate timeliness of multimodal treatments in a safety net breast cancer population.

METHODS

Breast cancer patients treated at a safety net hospital from 2016 to 2020 were analyzed retrospectively. Time intervals were defined as primary time (PT) from diagnosis to initiation of primary intervention, secondary time (ST) from completion of primary to initiation of secondary intervention, and tertiary time (TT) from completion of secondary to initiation of tertiary intervention. Variables included primary language, insurance type, and race.

RESULTS

Of 223 patients, 99 (44.4%) primarily spoke Spanish, 29 (13.0%) were of Black race, and 184 (82.5%) had Medicaid or uninsured status. Median (IQR) age at diagnosis was 55 (48-62) years. Primary intervention was surgical in 127/216 (58.8%); secondary intervention was systemic in 38/169 (22.5%); and tertiary intervention was radiation in 67/80 (83.8%). Overall, median days (IQR) for PT were 69 (53, 98), ST were 65 (42, 95), and TT were 69 (43, 88). PT was significantly longer in Black [105 (76, 142) days] patients compared to non-Hispanic White patients [68 (51, 107) days, P = 0.031)] and White Hispanic patients [65 (53,91) days, P = 0.014]. There were no significant differences in PT, ST, or TT by spoken language or insurance type.

CONCLUSIONS

Black patients remain at risk due to prolonged time to intervention. Spanish-speaking status was not associated with inferior timeliness or completion of multimodal care at a safety net hospital. Identifying safety net hospital barriers to achieving benchmarks for timely completion of all phases of multimodal care warrants further attention.

Cancer management during the COVID-19 world pandemic

Since 2019, the world has been experiencing an outbreak of a novel beta-coronavirus, severe acute respiratory syndrome coronavirus (SARS-CoV)-2. The worldwide spread of this virus has been a severe challenge for public health, and the World Health Organization declared the outbreak a public health emergency of international concern. As of June 8, 2023, the virus' rapid spread had caused over 767 million infections and more than 6.94 million deaths worldwide. Unlike previous SARS-CoV-1 and Middle East respiratory syndrome coronavirus outbreaks, the COVID-19 outbreak has led to a high death rate in infected patients; this has been caused by multiorgan failure, which might be due to the widespread presence of angiotensin-converting enzyme 2 (ACE2) receptors-functional receptors of SARS-CoV-2-in multiple organs. Patients with cancer may be particularly susceptible to COVID-19 because cancer treatments (e.g., chemotherapy, immunotherapy) suppress the immune system. Thus, patients with cancer and COVID-19 may have a poor prognosis. Knowing how to manage the treatment of patients with cancer who may be infected with SARS-CoV-2 is essential. Treatment decisions must be made on a case-by-case basis, and patient stratification is necessary during COVID-19 outbreaks. Here, we review the management of COVID-19 in patients with cancer and focus on the measures that should be adopted for these patients on the basis of the organs or tissues affected by cancer and by the tumor stage.

Primary lipofilling as an adjunct in transverse upper gracilis flap breast reconstruction

In many centres, the myocutaneous transverse upper gracilis (TUG) flap represents an alternative choice in autologous breast reconstruction when abdominal tissue is unavailable. However, a single TUG flap may be volume deficient, particularly in the upper pole. We describe the application of simultaneous lipofilling to the pectoralis major muscle at the index procedure and present our decision-making algorithm, technique and outcomes. A retrospective review of all TUG flaps between January 2011 and May 2021 was conducted. Patient demographics, volume of primary and any subsequent fat grafting and complications were recorded. A total of 183 patients (242 TUG flaps) were included in this study. Of these; 130 patients were reconstructed with single TUG flaps, 16 patients received a single TUG flap with immediate lipofilling, and 37 patients underwent stacked, double TUG flap reconstructions. Of the 242 flaps, there were 2 flap losses (<1%), neither of which occurred in the immediate lipofilling cohort. Among the 130 single TUG patients, 28 (21.5%) required a cumulative total of 40, and a mean of 1.4, secondary lipofilling procedures. The immediate lipofilling patients were injected with a mean of 42 ml fat (range: 20-80 ml). In this group, only 2 of 16 patients required secondary lipofilling. The mean follow-up was 67 months (17-141). Primary lipofilling may reduce the need for secondary revisional procedures and appears safe at the index operation, adds little operative time and has negligible donor site morbidity. In patients where a second (stacked) flap would add unnecessary volume and complexity, it can be considered a useful adjunct.

Impact of the COVID-19 pandemic on oncological care in Germany: rapid review

OBJECTIVES

The COVID-19 pandemic affected medical care for chronic diseases. This study aimed to systematically assess the pandemic impact on oncological care in Germany using a rapid review.

METHODS

MEDLINE, Embase, study and preprint registries and study bibliographies were searched for studies published between 2020 and 2 November 2022. Inclusion was based on the PCC framework: population (cancer), concept (oncological care) and context (COVID-19 pandemic in Germany). Studies were selected after title/abstract and full-text screening by two authors. Extracted data were synthesized using descriptive statistics or narratively. Risk of bias was assessed and summarized using descriptive statistics.

RESULTS

Overall, 77 records (59 peer-reviewed studies and 18 reports) with administrative, cancer registry and survey data were included. Disruptions in oncological care were reported and varied according to pandemic-related factors (e.g., pandemic stage) and other (non-pandemic) factors (e.g., care details). During higher restriction periods fewer consultations and non-urgent surgeries, and delayed diagnosis and screening were consistently reported. Heterogeneous results were reported for treatment types other than surgery (e.g., psychosocial care) and aftercare, while ongoing care remained mostly unchanged. The risk of bias was on average moderate.

CONCLUSIONS

Disruptions in oncological care were reported during the COVID-19 pandemic in Germany. Such disruptions probably depended on factors that were insufficiently controlled for in statistical analyses and evidence quality was on average only moderate. Research focus on patient outcomes (e.g., longer term consequences of disruptions) and pandemic management by healthcare systems is potentially relevant for future pandemics or health emergencies.

Experience with the safe admission of breast and thyroid cancer patients in non-endemic areas during an epidemic outbreak

Background

The outbreaks of infectious diseases, such as coronavirus disease 2019 (COVID-19), have seriously affected the normal work and life of the public, as well as the normal diagnosis and treatment of other diseases due to their strong infectivity, high population susceptibility, and diverse clinical manifestations. Breast and thyroid specialists in non-hotspot epidemic areas of COVID-19 must consider factors, including epidemic prevention and control, breast and thyroid cancers and diseases diagnosis and treatment, and access to medical resources to make a reasonable treatment choice and optimize the treatment process.

Methods

A cohort study was designed under our center's epidemic prevention and control strategy. The study was conducted between February 3 and April 19, 2020, to explore the safety of clinical diagnosis and treatment of breast and thyroid cancer patients during the epidemic. All the outpatients, inpatients, day-time chemotherapy patients, targeted therapy patients, and relevant medical staff in the observation period in the Department of Breast and Thyroid Surgery in Southwest Hospital in Chongqing municipality, China, were included to investigate the detection and infection rate of COVID-19 and suspected patients.

Results

During the observation period, 27,117 patients were admitted to the outpatient unit. We performed 394 inpatient surgeries and 411 day-time surgeries. In our center, 1,046 and 663 patients received day-time chemotherapy and targeted therapy, respectively. All the patients were diagnosed and treated promptly and safely. Three suspected COVID-19 patients were identified in the outpatient unit. Healthcare staff achieved a "zero" infection of COVID-19.

Conclusion

The spread and cross-infection of COVID-19 can be avoided in non-hotspot epidemic areas based on scientific prevention and control, and cancer patients can be diagnosed and treated on time. The prevention and control measure implemented in the COVID-19 epidemic for diagnosing and treating cancer patients was effective and can be referenced for other infectious disease outbreaks.

Intravenous Iron Therapy to Treat Anemia in Oncology: A Mapping Review of Randomized Controlled Trials

Anemia is a common problem when patients present with cancer, and it can worsen during treatment. Anemia can directly impact the cognitive and physical quality of life and may impair fitness for oncological therapy. The most common cause of anemia is iron deficiency. Newer intravenous (IV) iron formulations offer a safe and rapidly effective treatment option. We performed a systematic mapping review of randomized controlled trials (RCTs) evaluating intravenous iron therapy in patients with cancer and anemia and their outcomes. A total of 23 RCTs were identified. The median number of patients enrolled was 104 (IQR: 60-134). A total of 5 were focused on surgical outcomes (4 preoperative, 1 postoperative), and 15 were in adjuvant therapies for a variety of tumor types (breast, colorectal, lung, gynecological, myeloid, and lymphomas), 10 of which were in combination with erythropoietin-stimulating agents (ESAs) therapy, 2 in radiotherapy, and 1 in palliative care. Overall, the studies reported that the use of IV iron increased hemoglobin concentration and decreased transfusion rates during different cancer treatment regimes. IV iron can be administered safely throughout the cancer treatment pathway from primary surgery to the palliative setting. More studies are needed to demonstrate net clinical outcomes.

Delays in Initiating Anti-Cancer Therapy for Early-Stage Breast Cancer-How Slow Can We Go?

Breast cancer is the most commonly diagnosed cancer among women worldwide, and is a leading cause of cancer-related deaths. When diagnosed at an early stage, appropriate and timely treatment results in a high cure rate and better quality of life. Delays in initiating anti-cancer therapy, including surgical resection, adjuvant/neoadjuvant chemotherapy and radiation therapy are commonly encountered, even in developed health care systems. Existing comorbidities that mandate referral to other services, genetic counseling and testing that may dictate the extent and type of anti-cancer therapy and insurance coverage, are among the most commonly cited factors. However, delays can be unavoidable; for over three years, health care systems across the globe were busy dealing with the unprecedented COVID-19 pandemic. War across hot zones around the globe resulted in millions of refugees; most of them have no access to cancer care, and when/where available, there may be significant delays. Thus, cancer patients across the globe will probably continue to suffer from significant delays in diagnosis and appropriate treatment. Many retrospective reports showed significant negative impacts on different aspects of treatment outcomes and on patients' psychosocial wellbeing and productivity. In this paper, we review the available data on the impact of delays in initiating appropriate treatment on the outcomes of patients with early-stage breast cancer.

Impact of COVID-19 on 1-Year Survival Outcomes in Hepatocellular Carcinoma: A Multicenter Cohort Study

INTRODUCTION

The COVID-19 pandemic has caused severe disruption of healthcare services worldwide and interrupted patients' access to essential services. During the first lockdown, many healthcare services were shut to all but emergencies. In this study, we aimed to determine the immediate and long-term indirect impact of COVID-19 health services utilisation on hepatocellular cancer (HCC) outcomes.

METHODS

A prospective cohort study was conducted from 1 March 2020 until 30 June 2020, correlating to the first wave of the COVID-19 pandemic. Patients were enrolled from tertiary hospitals in the UK and Germany with dedicated HCC management services. All patients with current or past HCC who were discussed at a multidisciplinary meeting (MDM) were identified. Any delay to treatment (DTT) and the effect on survival at one year were reported.

RESULTS

The median time to receipt of therapy following MDM discussion was 49 days. Patients with Barcelona Clinic Liver Cancer (BCLC) stages-A/B disease were more likely to experience DTT. Significant delays across all treatments for HCC were observed, but delay was most marked for those undergoing curative therapies. Even though severe delays were observed in curative HCC treatments, this did not translate into reduced survival in patients.

CONCLUSION

Interruption of routine healthcare services because of the COVID-19 pandemic caused severe delays in HCC treatment. However, DTT did not translate to reduced survival. Longer follow is important given the delay in therapy in those receiving curative therapy.

Total Hip Arthroplasty With Prophylactic Fixation of Greater Trochanter and Distal Femur in a Patient With a History of Multiple Myeloma and Breast Cancer

Multiple myeloma is the most common primary malignancy of the bone marrow and may present as bone pain and/or pathologic fracture(s) in affected patients. Treatment of bone lesions typically consists of chemotherapy and radiation and may include prophylactic fixation in patients meeting specific criteria. This report reviews a case of a 74-year-old female with a history of multiple myeloma and breast cancer, previously treated with chemotherapy and radiation, who sustained a pathologic femoral neck fracture with associated ipsilateral lesions of the femoral shaft and peritrochanteric region. This patient received a total hip arthroplasty with a greater trochanteric claw plate and extended femoral stem for prophylactic fixation of the distal femur. In this report, the current literature surrounding the use of extended femoral stems for prophylactic fixation of femoral diaphyseal lesions will be reviewed and the above case will be presented. This case serves as a bridge between orthopedic oncology and arthroplasty as an extended femoral stem was used to prevent future pathologic fracture of distal femur lesions.

Outcomes of Rural Men with Breast Cancer: A Multicenter Population Based Retrospective Cohort Study

Background: Breast cancer is rare in men. This population-based study aimed to determine outcomes of male breast cancer in relation to residence and other variables. Methods: In this retrospective cohort study, men diagnosed with breast cancer in Saskatchewan during 2000–2019 were evaluated. Cox proportional multivariable regression analyses were performed to determine the correlation between survival and clinicopathological and contextual factors. Results: One hundred-eight eligible patients with a median age of 69 years were identified. Of them, 16% had WHO performance status ≥ 2 and 61% were rural residents. The stage at diagnosis was as follows: stage 0, 7%; I, 31%; II, 42%; III, 11%; IV, 8%. Ninety-eight percent had hormone receptor-positive breast cancer. The median disease-free survival of urban patients was 97 (95% CI: 50–143) vs. 64 (46–82) months of rural patients (p = 0.29). The median OS of urban patients was 127 (94–159) vs. 93 (32–153) months for rural patients (p = 0.27). On multivariable analysis, performance status ≥ 2, hazard ratio (HR) 2.82 (1.14–6.94), lack of adjuvant systemic therapy, HR 2.47 (1.03–5.92), and node-positive disease, HR 2.32 (1.22–4.40) were significantly correlated with inferior disease-free survival in early-stage invasive breast cancer. Whereas stage IV disease, HR 7.8 (3.1–19.5), performance status ≥ 2, HR 3.25 (1.57–6.71), and age ≥ 65 years, HR 2.37 (1.13–5.0) were correlated with inferior overall survival in all stages. Conclusions: Although residence was not significantly correlated with outcomes, rural men had numerically inferior survival. Poor performance status, node-positive disease, and lack of adjuvant systemic therapy were correlated with inferior disease-free survival.

Reverse Abdominoplasty for Mastectomy Defect Closure in Advanced Breast Cancer

BACKGROUND

Breast cancer patients with locally advanced breast cancer who require radical mastectomy are left with large chest wall defects. This poses a significant reconstructive challenge as many high-risk patients require timely postmastectomy adjuvant therapy. While the reverse abdominoplasty technique is commonly used for aesthetic improvement of the anterior trunk, it can be also be effectively used for closure of extensive mastectomy defects in this patient population.

METHODS

We conducted a retrospective cohort study of all consecutive patients who underwent an extensive radical mastectomy followed by immediate closure with the reverse abdominoplasty technique at a single tertiary cancer center from June 2017 to July 2022. Patients who had concurrent skin grafting or breast mound flap reconstruction were excluded. Demographic, medical, oncologic, and reconstructive data were collected.

RESULTS

Six patients were treated with reverse abdominoplasty for 9 chest wall defects after surgical excision of locally advanced breast cancer. The median tumor size was 10.7 cm (range, 6.7-10 cm) and the median mastectomy weight was 865.7 g (range, 356.4-1247.7 g). On average, the operation length was 191 minutes (range, 86-257 minutes) and the postoperative length of stay was 2.2 days (range, 1-5 days). All patients underwent systemic adjuvant therapy and the median time from surgery to initiation of therapy was 44.5 days (range, 32-75 days).

CONCLUSIONS

Reverse abdominoplasty is a simple and safe technique to reliably close large defects after locally advanced breast cancer excision. It has a short operative time, hospital stay, and turnaround time to initiation of adjuvant therapy.

Applying Lean Kaizen to Improve Timely Computed Tomography Scan Appointments for Oncology Patients in a Safety Net Hospital

PURPOSE

Timely radiographic studies are essential to oncology care. At our institution, a safety net hospital in a large metropolitan area, baseline assessment determined that the overwhelming majority of outpatient computed tomographic (CT) scans for oncology patients were overdue and not scheduled within 2 weeks of their first requested date.

METHODS

We conducted a series of structured, interdisciplinary meetings including staff from radiology, oncology, scheduling, and administration to critically review the scheduling process utilizing Lean Kaizen quality improvement methods. A new workflow was developed in which clinic staff scheduled CT scans before clinic discharge. Three months after our initial meeting, the new workflow was launched. We set a target of decreasing the percentage of overdue scans to below 20%.

RESULTS

At baseline, 87% (65 of 75) of CT scans awaiting scheduling were overdue. Data were gathered at 5 and 10 weeks after implementation of our workflow. The percentage of CT scans overdue for scheduling was 17% (9 of 53) at 5 weeks and 0.97% (1 of 103) at 10 weeks after implementation. Clinic visit durations were not affected.

CONCLUSION

The Lean Kaizen QI model was successful in decreasing the rate of oncology patients overdue for CT scan scheduling with minimal effects on clinic visit durations. This study demonstrated the importance of interdepartmental collaboration and continuous monitoring for improvement. Given the success of this project, this workflow will be expanded to other outpatient clinics within our institution.

The impact of lag time to cancer diagnosis and treatment on clinical outcomes prior to the COVID-19 pandemic: A scoping review of systematic reviews and meta-analyses

Background

The COVID-19 pandemic has disrupted cancer care, raising concerns regarding the impact of wait time, or 'lag time', on clinical outcomes. We aimed to contextualize pandemic-related lag times by mapping pre-pandemic evidence from systematic reviews and/or meta-analyses on the association between lag time to cancer diagnosis and treatment with mortality- and morbidity-related outcomes.

Methods

We systematically searched MEDLINE, EMBASE, Web of Science, and Cochrane Library of Systematic Reviews for reviews published prior to the pandemic (1 January 2010-31 December 2019). We extracted data on methodological characteristics, lag time interval start and endpoints, qualitative findings from systematic reviews, and pooled risk estimates of mortality- (i.e., overall survival) and morbidity- (i.e., local regional control) related outcomes from meta-analyses. We categorized lag times according to milestones across the cancer care continuum and summarized outcomes by cancer site and lag time interval.

Results

We identified 9032 records through database searches, of which 29 were eligible. We classified 33 unique types of lag time intervals across 10 cancer sites, of which breast, colorectal, head and neck, and ovarian cancers were investigated most. Two systematic reviews investigating lag time to diagnosis reported different findings regarding survival outcomes among paediatric patients with Ewing's sarcomas or central nervous system tumours. Comparable risk estimates of mortality were found for lag time intervals from surgery to adjuvant chemotherapy for breast, colorectal, and ovarian cancers. Risk estimates of pathologic complete response indicated an optimal time window of 7-8 weeks for neoadjuvant chemotherapy completion prior to surgery for rectal cancers. In comparing methods across meta-analyses on the same cancer sites, lag times, and outcomes, we identified critical variations in lag time research design.

Conclusions

Our review highlighted measured associations between lag time and cancer-related outcomes and identified the need for a standardized methodological approach in areas such as lag time definitions and accounting for the waiting-time paradox. Prioritization of lag time research is integral for revised cancer care guidelines under pandemic contingency and assessing the pandemic's long-term effect on patients with cancer.

Funding

The present work was supported by the Canadian Institutes of Health Research (CIHR-COVID-19 Rapid Research Funding opportunity, VR5-172666 grant to Eduardo L. Franco). Parker Tope, Eliya Farah, and Rami Ali each received an MSc. stipend from the Gerald Bronfman Department of Oncology, McGill University.

Initiatives to reduce the waiting time to initiate oncological treatment: a scoping literature review

Objective.

To identify the managerial actions proposed and employed to reduce the waiting time to initiate oncological treatments in the public health system and its application in Latin America.

Method.

We searched seven databases in December 2020. Search terms were conceptualized into three groups: waiting time, cancer, and terms related to public sector. The eligibility criteria included theoretical or empirical academic articles written in English, Spanish, or Portuguese, that focused on managerial solutions to face oncological healthcare queues' dilemma.

Results.

The search returned 1 255 articles, and 20 were selected and analysed in this review. Results show that most of the proposals are related to the process and people dimensions. The actions related to the process dimension were mainly associated with programming new treatment pathways and integrating cancer systems. People's dimension initiatives referred mostly to task forces and groups of specialists. Some initiatives were related to implementing technological solutions and the technology dimension, mainly concerning radiotherapy devices' acquisition.

Conclusion.

Few studies focus on analysing actions to minimize waiting time to initiate oncological treatments. The prevalence of conceptual and illustrative case studies indicates the lack of research maturity on this theme. Future studies should focus on setting the field's theoretical foundations, considering the existing paradigms, or developing new ones. There is a need for empirical studies applying a multidisciplinary approach to face the oncological treatment waiting time challenge and proposing new and innovative initiatives.

Factors contributing to delays in initiation of front-line cervical cancer therapy: disparities in a diverse south Florida population

Objective

Delay in initiating cervical cancer treatment may impact outcomes. In a cohort of patients initially treated by surgery, chemoradiation, chemotherapy, or in a clinical trial, we aim to define factors contributing to prolonged time to treatment initiation.

Methods

Data from patients initiating treatment for cervical cancer at a single institution was abstracted. Time to treatment initiation was defined as the interval from the date of cancer diagnosis to the date of treatment initiation. Poisson regression model was used for analysis.

Results

Of 274 patients studied, the median time to treatment initiation was 60 days (range 0–551). The median times to initiate surgery (54 days, range 3–96) and chemoradiation (58 days, range 4–187) were not significantly different (relative risk (RR) 1.01, 95% CI 0.98 to 1.04, p=0.54). The shortest median initiation time was for chemotherapy (47 days; RR 1.13, 95% CI 1.08 to 1.19, p<0.0001) and the longest was for clinical trial (62 days; RR 1.18, 95% CI 1.12 to 1.24, p<0.0001). Charity care (RR 1.09, 95% CI 1.05 to 1.14, p<0.0001), Medicare or Medicaid (RR 1.10, 95% CI 1.06 to 1.14, p<0.0001), and self-pay (RR 1.38, 95% CI 1.32 to 1.45, p<0.0001) delayed treatment initiation more than private insurance. Hispanic White women (RR 0.69, 95% CI 0.66 to 0.73, p<0.0001) had a shorter treatment initiation time compared with non-Hispanic White patients, while Afro-Caribbean/Afro-Latina women (RR 0.86, 95% CI 0.81 to 0.90, p<0.0001) and African-American patients (RR 1.13, 95% CI 1.07 to 1.19, p<0.0001) had longer initiation times. Spanish speaking patients did not have a prolonged treatment initiation (RR 0.68, 95% CI 0.66 to 0.71, p<0.0001), though Haitian-Creole speaking patients did (RR 1.07, 95% CI 1.01 to 1.13, p<0.002). Diagnosis at an outside institution delayed treatment initiation time (RR 1.24, 95% CI 1.18 to 1.30, p<0.0001) compared with diagnosis at the cancer center.

Conclusion

Factors associated with prolonged time to treatment initiation include treatment modality, insurance status, language spoken, and institution of diagnosis. By closely examining each of these factors, barriers to treatment can be identified and modified to shorten treatment initiation time.

Delay in the initiation of adjuvant chemotherapy in patients with breast cancer with mastectomy with or without immediate breast reconstruction

Background

Patients with breast cancer undergoing mastectomy should be offered the option of immediate breast reconstruction (IBR). The aim of this retrospective study was to assess whether there is a delay in the initiation of adjuvant chemotherapy in patients undergoing mastectomy with or without IBR.

Method

The study included patients aged 70 years or younger with clinically node-negative breast cancer who underwent unilateral mastectomy with IBR (IBR group) or mastectomy alone (no-IBR group) followed by adjuvant chemotherapy at the Helsinki University Hospital between January 2012 to July 2018.

Results

A total of 645 patients were included; 186 in the IBR group and 459 in the no-IBR group. Sixty-six (35.5 per cent) patients in the IBR group and 102 (22.2 per cent) patients in the no-IBR group received their first chemotherapy cycle later than 6 weeks after surgery (P &lt; 0.001). The respective numbers for later than 8 weeks were 17 (9.1 per cent) and 14 (3.1 per cent) (P = 0.001). Among all 645 patients, postoperative complications were a significant risk factor for a delay in the initiation of chemotherapy. Sixty-seven (39.9 per cent) patients with and 101 (21.2 per cent) patients without complications had a delay in chemotherapy (P &lt; 0.001). The delay in chemotherapy was due to complications in 39 (59.1 per cent) in the IBR group and in 28 (27.5 per cent) in the no-IBR group (P &lt; 0.001).

Conclusion

Patients undergoing mastectomy alone were more likely to receive adjuvant chemotherapy within 6 weeks after surgery compared with the IBR patients. IBR significantly increased the risk of postoperative complications in comparison with mastectomy alone. The complications, in turn, were a significant risk factor for delay in adjuvant chemotherapy.

An appropriate treatment interval does not affect the prognosis of patients with breast Cancer

Purpose

Major public health emergencies may lead to delays or alterations in the treatment of patients with breast cancer at each stage of diagnosis and treatment. How much do these delays and treatment changes affect treatment outcomes in patients with breast cancer?

Methods

This review summarized relevant research in the past three decades and identified the effect of delayed treatment on the prognosis of patients with breast cancer in terms of seeking medical treatment, neoadjuvant treatment, surgery, postoperative chemotherapy, radiotherapy, and targeted therapies.

Results

Delay in seeking medical help for ≥12 weeks affected the prognosis. Surgical treatment within 4 weeks of diagnosis did not affect patient prognosis. Starting neoadjuvant chemotherapy within 8 weeks after diagnosis, receiving surgical treatment at 8 weeks or less after the completion of neoadjuvant chemotherapy, and receiving radiotherapy 8 weeks after surgery did not affect patient prognosis. Delayed chemotherapy did not increase the risk of relapse in patients with luminal A breast cancer. Every 4 weeks of delay in the start of postoperative chemotherapy in patients with luminal B, triple-negative, or HER2-positive breast cancer treated with trastuzumab will adversely affect the prognosis. Targeted treatment delays in patients with HER2-positive breast cancer should not exceed 60 days after surgery or 4 months after diagnosis. Radiotherapy within 8 weeks after surgery did not increase the risk of recurrence in patients with early breast cancer who were not undergoing adjuvant chemotherapy.

Conclusion

Different treatments have different time sensitivities, and the careful evaluation and management of these delays will be helpful in minimizing the negative effects on patients.

The survival impact of palliative chemotherapy dose modifications on metastatic colon cancer

BACKGROUND

An uninterrupted dose of oxaliplatin-based cytotoxic therapy is an essential component in the standard treatment regimen of metastatic colon cancer (mCC). Data on the impacts of dose intensity reduction on the palliative treatment for patients with mCC remain scarce. Hence, this study aimed to investigate the impact of palliative chemotherapy dose modifications (DM) on the survival of patients with mCC.

METHODS

Patients with stage IV colon cancer who received first-line palliative FOLFOX regimen chemotherapy between 2014 until 2018 in the Oncology Department of the National Cancer Institute were conveniently sampled retrospectively to analyse the treatment efficacy. The cumulative dose and duration of chemotherapy received by the patients were summarised as relative dose intensity (RDI) and stratified as High RDI (RDI ≥ 70%) or Low RDI (RDI < 70%). Progression-free survival (PFS) and 2-year overall survival (OS) between the two groups were analysed using Kaplan-Meier survival analysis and Cox proportional hazards models.

RESULTS

Out of the 414 patients identified, 95 patients with mCC were eligible and included in the final analysis. About half of the patients (n = 47) completed the 12-cycle chemotherapy regimen and one patient received the complete (100%) RDI. The overall median RDI was 68.7%. The Low RDI group (n = 49) had a 1.5 times higher mortality risk than the High RDI group [OS, Hazard Ratio (HR) = 1.5, 95% Cl: 1.19-1.82] with a significant median OS difference (9.1 vs. 16.0 months, p <  0.01). Furthermore, patients with lower dose intensity showed double the risk of disease progression (PFS, HR = 2.0, 95% CI: 1.23-3.13) with a significant difference of 4.5 months of median PFS (p <  0.01). Gender and RDI were the independent prognostic factors of both OS and PFS.

CONCLUSION

Reduction in the dose intensity of palliative chemotherapy may adversely affect both disease progression and overall survival among mCC patients.

COVID-19 Vaccination in Patients with Cancer

Simple Summary

Patients with cancer are concerned about the effects of the COVID-19 vaccination while authorities search for ways to encourage vaccination; however, many points are still unclear. To remedy this situation, we conducted an online survey of 1182 female patients with cancer. The results showed that 768 were concerned about the vaccine, and 726 consulted with their attending physicians about the vaccination. The results also showed significantly higher vaccination rates among the patients who had consulted with their physicians. We found that consulting with attending physicians appeared to be linked to reduced anxiety, decisions about the timing of the vaccination, and higher vaccination rates. This was corroborated by the result of the cross-analysis of vaccination status and information sources about the vaccination. Therefore, we concluded that consulting with a physician about vaccination alleviates the concerns of patients with cancer and encourages them to get vaccinated.

Abstract

Patients with cancer are concerned about the effects of the COVID-19 vaccination. We conducted an online survey on the COVID-19 vaccination status and side effects among patients with cancer in Japan between 8 and 14 August 2021. We included 1182 female patients with cancer aged 20–70 years and registered on an online patient website. Of the patients, 944 had breast cancer, 216 had gynecological cancer, 798 were undergoing drug/radiation therapy, and 370 were in follow-up. At the time of the survey, 885 patients had already received at least one dose. Of these, 580 had also received their second dose. The incidence rate of side effects was equivalent to previous reports. In patients with breast cancer, problems such as the onset or worsening of lymphedema or axillary lymphadenopathy metastasis requiring differential diagnosis were encountered following vaccination. A total of 768 patients were concerned about the vaccine at some point, and 726 consulted with their attending physicians about the timing or side effects of the vaccination. Of the 110 patients undergoing chemotherapy or radiation therapy, 75 adjusted the timing of the vaccination based on their therapy. The cross-analysis revealed that 81% of those who consulted their physician had received at least one dose of the COVID-19 vaccination compared with 65% of those who had not consulted their physician. Consulting with a physician about the COVID-19 vaccination was found to alleviate the concerns of patients with cancer and encourage them to get vaccinated.

Early Return to Intended Oncologic Therapy after implementation of an Enhanced Recovery After Surgery pathway for gastric cancer surgery

PURPOSE

Time to initiation and completion of adjuvant therapy are critical to improve postoperative oncologic outcomes. This study aims to determine whether an Enhanced Recovery After Surgery (ERAS) pathway for gastric cancer surgery promotes early Return to Intended Oncologic Therapy (RIOT).

METHODS

This is a before-after intervention study including patients with gastric adenocarcinoma who underwent surgery from January 2016 to January 2021. Two periods were denoted based upon the implementation date of our institutional ERAS pathway (June 2018). Our primary outcome was time to RIOT after surgery. Hodges-Lehmann analysis was used to estimate median differences of non-parametric outcomes.

RESULTS

Seventy patients with gastric adenocarcinoma were included (35 in pre-ERAS period and 35 in post-ERAS period). Fourteen of the pre-ERAS and twenty-two patients of the post-ERAS period received adjuvant therapy. Time to RIOT was reduced in the post-ERAS period (median 39 days, IQR 31-49) by 12 days (95% CI 3-14 days, p = 0.01) compared to the pre-ERAS period (median 51 days, IQR 42-62). Length of hospital stay (LOS) was lower in the ERAS group (6 days, IQR 5-11 vs 10 days, IQR 8-13, p < 0.01).

CONCLUSION

Our institutional ERAS pathway for gastric cancer surgery was associated with earlier RIOT and shorter LOS.

Gaps in completion and timeliness of breast surgery and adjuvant therapy: a retrospective cohort of Haitian patients with nonmetastatic breast cancer

Background

There are limited data on breast surgery completion rates and prevalence of care-continuum delays in breast cancer treatment programs in low-income countries.

Methods

This study analyzes treatment data in a retrospective cohort of 312 female patients with non-metastatic breast cancer in Haiti. Descriptive statistics were used to summarize patient characteristics; treatments received; and treatment delays of > 12 weeks. Multivariate logistic regressions were performed to identify factors associated with receiving surgery and with treatment delays. Exploratory multivariate survival analysis examined the association between surgery delays and disease-free survival (DFS).

Results

Of 312 patients, 249 (80%) completed breast surgery. The odds ratio (OR) for surgery completion for urban vs. rural dwellers was 2.15 (95% confidence interval [CI]: 1.19–3.88) and for those with locally advanced vs. early-stage disease was 0.34 (95%CI: 0.16–0.73). Among the 223 patients with evaluable surgery completion timelines, 96 (43%) experienced delays. Of the 221 patients eligible for adjuvant chemotherapy, 141 (64%) received adjuvant chemotherapy, 66 of whom (47%) experienced delays in chemotherapy initiation. Presentation in the later years of the cohort (2015–2016) was associated with lower rates of surgery completion (75% vs. 85%) and with delays in adjuvant chemotherapy initiation (OR [95%CI]: 3.25 [1.50–7.06]). Exploratory analysis revealed no association between surgical delays and DFS.

Conclusion

While majority of patients obtained curative-intent surgery, nearly half experienced delays in surgery and adjuvant chemotherapy initiation. Although our study was not powered to identify an association between surgical delays and DFS, these delays may negatively impact long-term outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10549-022-06582-8.

Time to treatment and hospital visits for patients undergoing neoadjuvant chemotherapy for breast cancer in a single payer system

BACKGROUND AND OBJECTIVES

Neoadjuvant chemotherapy (NAC) requires coordination of various services to ensure timely and accurate delivery of care. This can result in multiple hospital visits and extend time to treatment (TTT). The primary purpose of our study was to evaluate time to NAC for patients at a regional cancer centre. Healthcare resource use in the form of hospital visits before NAC was also evaluated.

METHODS

A retrospective chart analysis of patients with invasive breast cancer who underwent NAC between 1 January 2012 and 31 December 2018 was performed.

RESULTS

Overall, 286 patients underwent NAC. Median TTT was 22 days (range: 2-105). Median number of visits between first consultation and NAC was 5 (range: 0-12). Majority of additional visits were for diagnostic imaging/interventions, with a median number of 4 visits (range: 0-10). Each additional hospital visit increased time to NAC treatment by 14%.

CONCLUSIONS

Women undergoing NAC require multiple visits before initiating treatment-the majority of these visits are for diagnostic imaging. These results support the need for the coordination of multidisciplinary care and diagnostic imaging for breast cancer patients undergoing NAC to reduce hospital visits, improve the patient experience, and reduce TTT.

Perioperative management of non-deferrable oncologic surgeries during COVID-19 pandemic in Madrid, Spain. Is it safe?

Introduction

Surgical treatment during Covid-19 pandemic is controversial. Currently, most clinical guidelines advise to defer surgical patients during the Covid-19 pandemic, although the supporting data is sparse. We assumed that a Covid-19-free hospital, on the back of strong isolation measures and targeted screening, could reduce complications and enable us to continue treating high-risk patients.

Methods

Prospective study with retrospective analysis of 355 patients who had undergone nondeferrable oncological surgery between March 16th, 2020, and April 14th, 2020, at our institution. The aim of the study was to assess the hospital restructuring and surgical protocols to be able to safely handle non-deferrable surgeries during the first wave of the Covid-19 pandemic. We implemented structural changes and an updated surgical-anesthetic protocol in order to isolate Covid-19 patients from other surgical patients. Comprehensive targeted screening for Covid-19 patients was made. PCR tests were requested for suspected Covid-19 patients. We analyzed mortality and complications related to both surgery and Covid-19 during hospital admission and also 15 and 30 days after surgery. We compared it with a sample of similar patients in the pre-pandemic period.

Results

Of the 355 patients enrolled in our study, 21 were removed due to Covid-19 infection, leaving a total of 334 patients in our final analysis. Post-operative complications were found in 37 patients (11.07%). Two patients died after surgery (0.6%). At the end of the study, Covid-19-related adverse outcomes were detected in six patients (1.79%). When comparing the complications of our original sample with the complications that occurred in the pre-covid era, we found no statistically significant differences.

Conclusions

Our results show that the surgical treatment of oncologic patients during the Covid-19 pandemic is safe, as long as the hospital performs surgeries under strict isolation measures and a robust screening method. It is necessary to select Covid-19 free hospitals for this matter in this and future pandemics.

The Impact of Radiotherapy Delay in Breast Conservation Patients Not Receiving Chemotherapy and the Rationale for Dichotomizing the Radiation Oncology Time-Dependent Standard into Two Quality Measures

INTRODUCTION

The Commission on Cancer/National Quality Forum breast radiotherapy quality measure establishes that for women < 70 years, adjuvant radiotherapy after breast conserving surgery (BCS) should be started < 1 year from diagnosis. This was intended to prevent accidental radiotherapy omission or delay due to a long interval between surgery and chemotherapy completion, when radiation is delivered. However, the impact on patients not receiving chemotherapy, who proceed from surgery directly to radiotherapy, remains unknown.

PATIENTS AND METHODS

Patients aged 18-69, diagnosed with stage I-III breast cancer as their first and only cancer diagnosis (2004-2016), having BCS, for whom this measure would be applicable, were reviewed from the National Cancer Database.

RESULTS

Among 308,521 patients, the median age was 57.0 years, and > 99% of all patients were compliant with the measure. The cohort of interest included 186,650 (60.5%) patients not receiving chemotherapy, with a mean age of 57.9 years. Of these, 90.5% received external beam radiotherapy (EBRT) and 9.5% brachytherapy. Among them, 24.9% started radiotherapy > 8 weeks after surgery. In a multivariable model, delay from surgery to radiotherapy increased the hazard ratios for overall survival to 9.0% (EBRT) per month and 3.0% (brachytherapy) per week.

CONCLUSION

While 99.9% of patients undergoing BCS without chemotherapy remain compliant with the current quality measure, 25% have delays > 8 weeks to start radiation, which is associated with impaired survival. These data suggest that the current quality measure should be dichotomized into two, with or without chemotherapy, in order to impel prompt radiotherapy initiation and maximize outcomes in all patients.

Young Women with Breast Cancer: Chemotherapy or Surgery First? An Evaluation of Time to Treatment for Invasive Breast Cancer

Background

Breast cancer in young women (ages 18–40 years) is rare, yet remains a leading cause of cancer-related death. Time to treatment (TTT) is an increasingly important factor in breast cancer outcomes, specifically time to systemic therapy. Our objective was to review patterns of care for young women presenting with invasive breast cancer and compare TTT for surgery first versus neoadjuvant chemotherapy (NAC).

Patients and Methods

A retrospective chart review of young women with non-metastatic, non-inflammatory invasive breast cancer between 2012 and 2018 at a single institution was completed. The primary outcome was time to first treatment (surgery or NAC).

Results

One hundred forty-two young women were treated for invasive breast cancer during the study period. The majority of patients underwent surgery first (57.7%) compared with NAC (42.3%). Women who underwent NAC were more likely to have abnormal lymph nodes on imaging (p = 0.002) and clinical exam (p < 0.0001) and were also more likely to have larger tumor sizes (p < 0.05). The majority of triple negative patients underwent NAC first (88% [14/16]). Median TTT was significantly longer for surgery (27 [range 7–70] days) versus (20.5 [3–50] days) chemotherapy (p = 0.004). Median number of additional hospital visits prior to surgery was 4 (range 1–8) versus 5 (0–11) for NAC (p < 0.001).

Conclusions

Young women with breast cancer who undergo NAC have a shorter TTT and clinically similar median number of hospital visits compared with women undergoing surgery first. These results support the use of NAC in young women, when indicated, as additional workup and consultations prior to NAC do not delay care.

Primary Care Continuity and Wait Times to Receiving Breast Cancer Chemotherapy: A Population-Based Retrospective Cohort Study Using CanIMPACT Data

(1) Background: Wait times to chemotherapy are associated with morbidity and mortality in breast cancer patients; however, it is unclear how primary care physician (PCP) continuity impacts these wait times, or whether this association is different in immigrants, who experience cancer care inequities. We assessed the association between PCP continuity and the contact-to-chemotherapy interval (wait time from when a patient first presents to healthcare to the first day of receiving breast cancer chemotherapy), with a specific look at the immigrant population. (2) Methods: Population-based, retrospective cohort study of women who were diagnosed with stage I–III breast cancer in Ontario who received surgery and adjuvant chemotherapy. We used quantile regression at the median and 90th percentile to quantify the effect of PCP continuity on the contact-to-chemotherapy interval, performing a separate analysis on the immigrant population. (3) Results: Among 12,781 breast cancer patients, including 1706 immigrants, the median contact-to-chemotherapy interval (126 days) was 3.21 days shorter (95% confidence interval (CI) 0.47–5.96) in symptom-detected patients with low PCP continuity, 10.68 days shorter (95% CI 5.36–16.00) in symptom-detected patients with no baseline PCP visits and 17.43 days longer (95% CI 0.90–34.76) in screen-detected immigrants with low PCP continuity compared to the same groups with high PCP continuity. (4) Conclusions: Higher PCP continuity was not associated with a change in the contact-to-chemotherapy interval for most of our study population, but was associated with a marginally longer interval in our symptom-detected population and a shorter contact-to-chemotherapy interval in screen-detected immigrants. This highlights the importance of PCP continuity among immigrants with positive screening results. Additionally, having no PCP visits at baseline was associated with a shorter contact-to-chemotherapy interval in symptom-detected patients.

The Relationship between Time to Surgery (TTS) and Survival in Breast Cancer: A Systematic Review and Meta-Analysis

Background:

Curative operation is the practical and primary therapy for masses of breast cancers. In contrast, the correlation between the time interval from breast cancer diagnosis to curative surgery and survival is still uncertain.

Methods:

An electronic literature search was conducted on PubMed/Medline and EMBASE (between Jan 2000 and Jan 2020). Primary endpoints were overall survival (OS) or Disease-Free Survival (DFS). The HR with 95% confidence intervals were calculated using a random-effects or fixed-effects model.

Results:

The combined HR for OS was 1. 10 (95% CI 1. 08–1. 11; P=0. 000) by fixed-effects model, no statistically significant heterogeneity was found (P=1. 000; I2=0%), and this difference was statistically significant (Z=11. 99; P=0. 000).

Conclusion:

This meta-analysis showed a significant adverse association between more prolonged time to surgery (TTS) and lower overall survival in patients with breast cancer. It is reasonable to minimize that interval between diagnosis and curative surgery.

Factors delaying chemotherapy in patients with breast cancer at a safety-net hospital

BACKGROUND

Despite advances in healthcare and improved chemotherapy, disparities in breast cancer outcomes continue to persist. Our aim was to evaluate socioeconomic factors that may impact timing of treatment for patients receiving chemotherapy in underserved communities.

METHODS

A review of patients with breast cancer who received neoadjuvant or adjuvant chemotherapy from 2015-2019 was conducted at a safety-net hospital. The primary outcomes were times from diagnosis to chemotherapy and surgery. Clinicodemographic factors including race, age, clinical stage, primary language, comorbidities, and median income by zip code were collected. Multivariable regression analysis was performed to evaluate for factors associated with the primary outcomes.

RESULTS

One hundred patients were identified. For the neoadjuvant group, median time from diagnosis to chemotherapy and surgery was 52 ± 34 days and 256 ± 59 days, respectively. For the adjuvant group, median time from diagnosis to surgery and chemotherapy was 24.5 ± 18 days and 94.5 ± 53 days, respectively. Non-English language and older age were associated with increased time to chemotherapy in the adjuvant group (p < 0.05). Language and age were not associated with increased time to surgery in both groups. Race, age, comorbidities, and income were not associated with delay in treatment in either groups.

CONCLUSIONS

Older age and non-English language were associated with prolonged time from surgery to adjuvant chemotherapy. Targeted interventions directed at patient education and decreasing language barriers especially post-operatively may decrease delays in treatment and subsequently reduce disparities seen in the breast cancer population.

Can supine breast magnetic resonance imaging help hit the target in extreme oncoplastic surgery?

OBJECTIVES

To evaluate the clinical value of supine magnetic resonance imaging (MRI) for tumor localization in breast cancer patients with large or multifocal tumors detected by prone MRI, scheduled for oncoplastic breast conserving surgery (OBCS). Outcomes were compared with those of patients who underwent wide local excision (WLE) or OBCS without MRI guidance.

METHODS

Over a 2-year period, consecutive patients with large or multifocal disease scheduled for OBCS with MRI-only findings were invited to participate (Group-1). Supplementary supine MRI was performed, and tumor margins were marked in the surgical position. Consecutive patients with early, non-palpable breast cancer who underwent WLE (Group-2) or OBCS (Group-3) were included for comparisons. The primary outcome was reoperation due to an insufficient margin. Secondary outcomes included surgical complications and delayed adjuvant treatment.

RESULTS

Altogether, 102 breasts (98 patients) were analyzed. All preoperative demographic data were comparable among the three groups. Multifocality, tumor-to-breast volume ratio, and the volume of excised breast tissue were significantly greater in Group-1 than in Groups-2 and 3. Operation time was longer and the need for axillary clearance or surgery for both breasts was more common in Groups-1 and 3 than in Group-2. Adequate margins were achieved in all patients in Groups-1 and 2, and one patient underwent re-excision in Group-3.

CONCLUSIONS

Supine MRI in the surgical position is a new, promising method to localize multifocal, large tumors visible on MRI. Its short-term outcomes were comparable with those of conventional WLE and OBCS.

Time to Completion of Breast Cancer Treatment and Survival

BACKGROUND

Breast cancer treatment delays are common. This study was designed to examine the association between the time interval from time of diagnosis to completion of all acute breast cancer treatment modalities (surgery, chemotherapy, and radiation therapy) and survival.

METHODS

A retrospective analysis was performed utilizing data from the National Cancer Database (NCDB) to determine an association between the duration of time from diagnosis to completing all acute breast cancer treatment (surgery, chemotherapy, and radiation therapy) and survival. Secondary survival analysis evaluated whether delay in treatment completion varied by differences in tumor receptor status.

RESULTS

We analyzed 2010 NCDB data of stage I-III breast cancer patients. A subset of 28,284 patients received all three modalities (surgery, chemotherapy, and radiation) as their acute treatment. Median follow-up was 5.8 years. Cox proportional hazards model identified a cut-off showing the risk of delaying completion of all treatment beyond 38 weeks was associated with a decrease in overall survival (hazard ratio [HR] 1.21). This decrease in survival was significant regardless of the major tumor receptor status: triple-negative (HR 1.188, 95% confidence interval [CI] 1.06-1.34), estrogen receptor (ER)+/progesterone receptor (PR)+/human epidermal growth factor receptor 2 (HER2)- (HR 1.22, 95% CI 1.09-1.36), ER-/PR-/HER2+ (HR 1.29, 95% CI 1.004-1.67), and ER+/PR+/HER2+ (HR 1.32, 95% CI 1.01-1.72).

CONCLUSION

Efforts to improve the efficiency of multimodality breast cancer treatment and reduce treatment delays should be a priority to optimize breast cancer patient outcomes.

Determinants of enhanced vulnerability to coronavirus disease 2019 in UK patients with cancer: a European study

BACKGROUND

Despite high contagiousness and rapid spread, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has led to heterogeneous outcomes across affected nations. Within Europe (EU), the United Kingdom (UK) is the most severely affected country, with a death toll in excess of 100,000 as of January 2021. We aimed to compare the national impact of coronavirus disease 2019 (COVID-19) on the risk of death in UK patients with cancer versus those in continental EU.

METHODS

We performed a retrospective analysis of the OnCovid study database, a European registry of patients with cancer consecutively diagnosed with COVID-19 in 27 centres from 27th February to 10th September 2020. We analysed case fatality rates and risk of death at 30 days and 6 months stratified by region of origin (UK versus EU). We compared patient characteristics at baseline including oncological and COVID-19-specific therapy across UK and EU cohorts and evaluated the association of these factors with the risk of adverse outcomes in multivariable Cox regression models.

FINDINGS

Compared with EU (n = 924), UK patients (n = 468) were characterised by higher case fatality rates (40.38% versus 26.5%, p < 0.0001) and higher risk of death at 30 days (hazard ratio [HR], 1.64 [95% confidence interval {CI}, 1.36-1.99]) and 6 months after COVID-19 diagnosis (47.64% versus 33.33%; p < 0.0001; HR, 1.59 [95% CI, 1.33-1.88]). UK patients were more often men, were of older age and have more comorbidities than EU counterparts (p < 0.01). Receipt of anticancer therapy was lower in UK than in EU patients (p < 0.001). Despite equal proportions of complicated COVID-19, rates of intensive care admission and use of mechanical ventilation, UK patients with cancer were less likely to receive anti-COVID-19 therapies including corticosteroids, antivirals and interleukin-6 antagonists (p < 0.0001). Multivariable analyses adjusted for imbalanced prognostic factors confirmed the UK cohort to be characterised by worse risk of death at 30 days and 6 months, independent of the patient's age, gender, tumour stage and status; number of comorbidities; COVID-19 severity and receipt of anticancer and anti-COVID-19 therapy. Rates of permanent cessation of anticancer therapy after COVID-19 were similar in the UK and EU cohorts.

INTERPRETATION

UK patients with cancer have been more severely impacted by the unfolding of the COVID-19 pandemic despite societal risk mitigation factors and rapid deferral of anticancer therapy. The increased frailty of UK patients with cancer highlights high-risk groups that should be prioritised for anti-SARS-CoV-2 vaccination. Continued evaluation of long-term outcomes is warranted.

Factors Involved in Delaying Initiation of Adjuvant Chemotherapy After Breast Cancer Surgery

BACKGROUND

Delays in initiating adjuvant chemotherapy after breast cancer surgery seems to have an impact on patients' risk of relapse and their survival rate. The aim of this retrospective study was to identify factors delaying initiation of adjuvant chemotherapy after breast surgery.

MATERIAL AND METHODS

All patients undergoing surgical treatment for mammary cancer between June 2014 and June 2015 and receiving adjuvant chemotherapy were selected retrospectively.

RESULTS

In multivariate analysis, 3 factors significantly delay initiation of adjuvant chemotherapy: a secondary procedure (odds ratio [OR], 6.67; P = .00012), inclusion in a therapeutic trial (OR, 8.46; P = .0013), and a positive HER2 status (OR, 3.02; P = .063 [statistically significant]).

DISCUSSION

This study provides a brief overview of the population most likely to experience a delay in the initiation of their adjuvant chemotherapy after cancer surgery. Our findings should assist interventions during initial management.

Impact of timing of adjuvant chemothapy for early breast cancer: the Royal Marsden Hospital experience

BACKGROUND

The optimal time to deliver adjuvant chemotherapy has not been defined.

METHODS

A retrospective study of consecutive patients receiving adjuvant anthracycline and/or taxane 1993-2010. Primary endpoint included 5-year disease-free survival (DFS) in patients commencing chemotherapy <31 versus ≥31 days after surgery. Secondary endpoints included 5-year overall survival (OS) and sub-group analysis by receptor status.

RESULTS

We identified 2003 eligible patients: 1102 commenced chemotherapy <31 days and 901 ≥31 days after surgery. After a median follow-up of 115 months, there was no difference in 5-year DFS rate with chemotherapy <31 compared to ≥31 days after surgery in the overall population (81 versus 82% hazard ratio (HR) 1.15, 95% confidence interval (95% CI) 0.92-1.43, p = 0.230). The 5-year OS rate was similar in patients who received chemotherapy <31 or ≥31 days after surgery (90 versus 91%, (HR 1.21, 95% CI 0.89-1.64, p = 0.228). For 250 patients with triple-negative breast cancer OS was significantly worse in patients who received chemotherapy ≥31 versus <31 days (HR = 2.18, 95% CI 1.11-4.30, p = 0.02).

DISCUSSION

Although adjuvant chemotherapy ≥31 days after surgery did not affect DFS or OS in the whole study population, in TN patients, chemotherapy ≥31 days after surgery significantly reduced 5-year OS; therefore, delays beyond 30 days in this sub-group should be avoided.

Perioperative management of non-deferrable oncologic surgeries during COVID-19 pandemic in Madrid, Spain. Is it safe?

INTRODUCTION

Surgical treatment during COVID-19 pandemic is controversial. Currently, most clinical guidelines advise to defer surgical patients during the COVID-19 pandemic, although the supporting data is sparse. We assumed that a COVID-19-free hospital, on the back of strong isolation measures and targeted screening, could reduce complications and enable us to continue treating high-risk patients.

METHODS

Prospective study with retrospective analysis of 355 patients who had undergone nondeferrable oncological surgery between March 16th, 2020, and April 14th, 2020, at our institution. The aim of the study was to assess the hospital restructuring and surgical protocols to be able to safely handle non-deferrable surgeries during the first wave of the COVID-19 pandemic. We implemented structural changes and an updated surgical-anesthetic protocol in order to isolate COVID-19 patients from other surgical patients. Comprehensive targeted screening for COVID-19 patients was made. PCR tests were requested for suspected COVID-19 patients. We analyzed mortality and complications related to both surgery and COVID-19 during hospital admission and also 15 and 30 days after surgery. We compared it with a sample of similar patients in the pre-pandemic period.

RESULTS

Of the 355 patients enrolled in our study, 21 were removed due to COVID-19 infection, leaving a total of 334 patients in our final analysis. Post-operative complications were found in 37 patients (11.07%). Two patients died after surgery (0.6%). At the end of the study, COVID-19-related adverse outcomes were detected in six patients (1.79%). When comparing the complications of our original sample with the complications that occurred in the pre-COVID era, we found no statistically significant differences.

CONCLUSIONS

Our results show that the surgical treatment of oncologic patients during the COVID-19 pandemic is safe, as long as the hospital performs surgeries under strict isolation measures and a robust screening method. It is necessary to select COVID-19 free hospitals for this matter in this and future pandemics.

Mortality and morbidity of curative and palliative anticancer treatments during the COVID-19 pandemic: A multicenter population-based retrospective study

Administration of effective anticancer treatments should continue during pandemics. However, the outcomes of curative and palliative anticancer treatments during the coronavirus disease (COVID-19) pandemic remain unclear. The present retrospective observational study aimed to determine the 30-day mortality and morbidity of curative and palliative anticancer treatments during the COVID-19 pandemic. Between March 1 and June 30, 2020, all adults (n=2,504) with solid and hematological malignancies irrespective of cancer stage and type of anticancer treatments at five large comprehensive cancer centers in Saudi Arabia were included. The 30-day mortality was 5.1% (n=127) for all patients receiving anticancer treatment, 1.8% (n=24) for curative intent, 8.6% (n=103) for palliative intent and 13.4% (n=12) for COVID-19 cases. The 30-day morbidity was 28.2% (n=705) for all patients, 17.9% (n=234) for curative intent, 39.3% (n=470) for palliative intent and 75% (n=77) for COVID-19 cases. The 30-day mortality was significantly increased with male sex [odds ratio (OR), 2.011; 95% confidence interval (CI), 1.141-3.546; P=0.016], body mass index (BMI) <25 (OR, 1.997; 95% CI, 1.292-3.087; P=0.002), hormone therapy (OR, 6.315; 95% CI, 0.074-2.068; P=0.001) and number of cycles (OR, 2.110; 95% CI, 0.830-0.948; P=0.001), but decreased with Eastern Cooperative Oncology Group performance status (ECOG-PS) of 0-1 (OR, 0.157; 95% CI, 0.098-0.256; P=0.001), stage I-II cancer (OR, 0.254; 95% CI, 0.069-0.934; P=0.039) and curative intent (OR, 0.217; 95% CI, 0.106-0.443; P=0.001). Furthermore, the 30-day morbidity significantly increased with age >65 years (OR, 1.420; 95% CI, 1.075-1.877; P=0.014), BMI <25 (OR, 1.484; 95% CI, 1.194-1.845; P=0.001), chemotherapy (OR, 1.397; 95% CI, 1.089-5.438; P=0.032), hormone therapy (OR, 1.527; 95% CI, 0.211-1.322; P=0.038) and immunotherapy (OR, 1.859; 95% CI, 0.648-4.287; P=0.038), but decreased with ECOG-PS of 0-1 (OR, 0.502; 95% CI, 0.399-0.632; P=0.001), breast cancer (OR, 0.569; 95% CI, 0.387-0.836; P=0.004) and curative intent (OR, 0.410; 95% CI, 0.296-0.586; P=0.001). The mortality risk was lowest with curative treatments. Therefore, such treatments should not be delayed. The morbidity risk doubled with palliative treatments and was highest among COVID-19 cases. Mortality appeared to be driven by male sex, BMI <25, hormonal therapy and number of cycles, while morbidity increased with age >65 years, BMI <25, chemotherapy, hormonal therapy and immunotherapy. Therefore, oncologists should select the most effective anticancer treatments based on the aforementioned factors.

Appraising the quality of meta-analysis for breast cancer treatment in the adjuvant setting: A systematic review

INTRODUCTION

Breast cancer is the tumor with highest incidence in women worldwide and adjuvant treatment is extremely important to achieve disease control. Given the relevance of systematic reviews, their rigor should be warranted to avoid biased conclusions. Our objective was to investigate the methodological quality of meta-analysis of early breast cancer adjuvant treatment.

MATERIAL AND METHODS

Comprehensive searches were performed using electronic databases from 1/1/2007 to 11/12/2018. All studies identified as a systematic review with meta-analysis investigating the efficacy of breast cancer adjuvant treatments were included. Two reviewers independently assessed titles and abstracts, then full-texts for eligibility. Quality was assessed using the Assessing the Methodological Quality of Systematic Reviews (AMSTAR) version 2 tool.

RESULTS

Of 950 citations retrieved, 66 studies (7.0%) were deemed eligible. Methodological quality was highly variable, median AMSTAR score 8.5 (IQR 7-9.5) and range 0-16. There was a weak positive correlation between journal impact factor and AMSTAR score (r = 0.17) and citation rate and AMSTAR score (r = 0.16). Cochrane Systematic Reviews were of higher quality than reviews from other journals. Overall confidence was critically low for 61 (92.4%) studies, and the least well-reported domains were the statement of conflict of interest and funding source for the included studies (4.6%), the report of a pre-defined study protocol (15.2%), and the description of details of excluded studies (6.1%).

CONCLUSIONS

Our findings reinforce concerns about the design, conduction and interpretation of meta-analysis in current literature. Methodological quality should be carefully considered and journal editors, decision makers and readers in general, must follow a critical approach to this studies.

Real-world anticancer medications for reproductive-age women with breast cancer by using a claims database in Japan

Aim: To describe real-world breast cancer medications among reproductive-age women. Patients & methods: Using data from a Japanese claims database, anticancer prescriptions were classified into seven categories of amenorrhea risk based on fertility preservation guidelines. Results: We identified 2999 women with records of breast cancer and anticancer prescription from 2005 to 2018. The proportions of prescriptions were as follows: high, 4.1-12.9%; intermediate: 6.0-16.3%; low: 0.4-2.3%; very low/no: 0.3-12.2%; unknown: 33.9-45.5%; unlisted combination: 12.2-23.4%; and unlisted drug: 12.5-26.7%. The common drugs in the unknown category were trastuzumab (n = 1527), docetaxel (n = 1014), and paclitaxel (n = 995). For medications unlisted in the guidelines, various drugs and drug combinations were observed. Conclusion: Numerous anticancer drugs are currently being prescribed with insufficient evidence regarding amenorrhea risk.

Fertility preservation for cancer patients: treatment gaps and considerations in patients' choices

PURPOSE

Women with cancer may desire fertility preservation (FP) prior to initiating cancer treatment, but undergoing FP may result in treatment delays. This study sought to determine whether such delays existed in our population and which factors were associated with patients' decision to proceed with FP.

METHODS

This was a historical cohort study performed at Montefiore Medical Center's Institute for Reproductive Medicine and Health. Reproductive age women diagnosed with cancer and consulted for FP were included. The main outcome measure was the number of days between FP consultation and cancer treatment initiation. Factors associated with patients' decisions to proceed with FP were also analyzed.

RESULTS

Thirty out of 51 women in our study underwent FP including embryo cryopreservation, oocyte cryopreservation, ovarian tissue cryopreservation (OTC), both oocyte and embryo cryopreservation, or GnRH agonist treatment. The majority of women who underwent FP chose embryo cryopreservation (36.7%), followed by oocyte cryopreservation (33.3%). Of the 20 patients with partners who underwent FP, 13 (65%) froze embryos. Only 4 of the 30 women who underwent FP had all, or a portion of their services, covered by insurance. The mean treatment delay was 18 days (p = 0.007), with a mean consultation to oncologic treatment gap of 23 ± 16.8 and 41.4 ± 25.9 days in the non-FP and FP groups, respectively.

CONCLUSION

Women with cancer diagnosis who underwent FP prior to initiating cancer treatment experienced a statistically significant delay in initiating cancer treatment. However, the clinical significance of this finding is unknown since FP treatments have not been associated with increased recurrence or mortality.

Associated factors and outcomes of delaying adjuvant chemotherapy in breast cancer by biologic subtypes: a National Cancer Database study

Purpose

Several studies have evaluated the role of delayed initiation of adjuvant chemotherapy (AC) in breast cancer (BC), but the results have remained controversial and an optimal time has not been defined. Our aim was to determine the effect of time to starting AC from the date of surgery on survival of BC patients, based on estrogen receptor (ER), progesterone receptor (PR) and human epidermal growth factor receptor 2 (HER2) status, using data from the National Cancer Database (NCDB).

Methods

A total of 332,927 Stage I–III BC patients who received AC from 2010 to 2016 were analyzed. We included all ER, PR and HER2 statuses and excluded patients with stage 4 and stage 0 (DCIS) disease. The cohort was divided into five groups based on the time of initiating AC from the date of the most definitive surgery i.e., ≤ 30 days, 31–60 days, 61–90 days, 91–120 days and > 120 days. They were further divided into five subgroups based on the receptor status.

Results

Hazard ratio (HR) estimates and Kaplan–Meier (KM) analysis shows that starting AC by 31–60 days shows the best survival outcome in all the subtypes, except in hormone positive/HER2 negative BC in which 31–60 days and 61–90 days have similar outcomes.

Conclusions

After surgery for BC, it takes around 4–6 weeks to begin AC and delay in initiating the same leads to poor outcomes. Our results are particularly significant in triple-negative breast cancer (TNBC), similar to prior studies showing a benefit to starting AC as early as possible after surgery.

Medical Liability in Cancer Care During COVID-19 Pandemic: Heroes or Guilty?

Background: The COVID-19 outbreak rapidly became a public health emergency affecting particularly the frail category as cancer patients. This led oncologists to radical changes in patient management, facing the unprecedent issue whether treatments in oncology could be postponed without compromising their efficacy.

Purpose: To discuss legal implications in oncology practice during the COVID-19 pandemic.

Perspective: Treatment delay is not always feasible in oncology where the timing often plays a key role and may impact significantly in prognosis. During the COVID-19 pandemic, the oncologists were found between the anvil and the hammer, on the one hand the need to treat cancer patients aiming to improve clinical benefits, and on the other hand the goal to reduce the risk of COVID-19 infection avoiding or delaying immunosuppressive treatments and hospital exposure. Therefore, two rising scenarios with possible implications in both criminal and civil law are emerging. Firstly, oncologists may be “accused” of having delayed or omitted the diagnosis and/or treatments with consequent worsening of patients' outcome. Secondly, oncologists can be blamed for having exposed patients to hospital environment considered at risk for COVID-19 transmission.

Conclusions: During the COVID-19 pandemic, clinical decision making should be well-balanced through a careful examination between clinical performance status, age, comorbidities, aim of the treatment, and the potential risk of COVID-19 infection in order to avoid the risk of suboptimal cancer care with potential legal repercussion. Moreover, all cases should be discussed in the oncology team or in the tumor board in order to share the best strategy to adopt case by case.

The Impact of Postoperative Wound Complications on Oncological Outcomes Following Immediate Breast Reconstruction for Breast Cancer: A Meta-analysis

The association between immediate breast reconstruction (IBR)-related wound complications and breast cancer recurrence (BCR) remains uncertain. This study aimed to investigate the oncological outcomes in patients with wound complications following mastectomy and IBR. A comprehensive search was undertaken for all studies describing complications in patients with breast cancer following IBR. Studies were included if they reported on complications and investigated their relationship with BCR. A meta-analysis was performed using a random-effects model, with data presented as odds ratios and 95% confidence intervals. A total of 1418 patients from five studies were included in the final analysis. The mean age of patients included was 47.2 years. A total of 382 (26.9%) patients had postoperative complications following a majority of implant-based IBR (929/1418). A total of 158 (11.1%) recurrences, which included 63 locoregional and 106 distant recurrences, was noted at a mean follow-up of 66 months. Although there was an increase in recurrence rates in the complication group (n = 66/382; 17.3% vs. n = 92/1036; 8.9%), there was no significant association between complications and BCR (17.3% vs. 8.9%; P = .18) or mortality (3.6% vs. 2.3%; P = .15). Time to adjuvant therapy was significantly increased in patients with complications (mean difference, 8.69 days; range, 1.18-16.21 days; P = .02; I² = 0.02). This meta-analysis demonstrated a higher incidence of wound complications following IBR and a statistically significant increased time to adjuvant therapy. However, this did not translate into adverse oncological outcomes in patients with breast cancer undergoing IBR.

Early Expander-to-Implant Exchange after Postmastectomy Reconstruction Reduces Rates of Subsequent Major Infectious Complications

Major infectious complications after implant-based postmastectomy reconstruction commonly occur late (>30 days postoperative). We set out to determine if early expander-to-implant exchange (3-6 weeks after tissue expander placement) reduced rates of subsequent major infectious complications.

METHODS

We retrospectively examined patients after mastectomy and tissue expander reconstruction followed by early expander-to-implant exchange versus exchange at least 6 months after initial tissue expander placement (the control group). Multivariate logistic regression analysis was performed to determine whether the timing of implant exchange independently predicted major infectious complications occurring more than 30 days after initial tissue expander placement after adjusting for differences in patient variables between groups.

RESULTS

In total, 252 consecutive patients (430 breasts) between August 2014 and October 2019 were included. While the rates of major early infectious complications after mastectomy and tissue expander placement were similar between the groups, the control group had more subsequent major infectious complications during the reconstructive process [9.8% (n = 22) versus 1.9% (n = 4), P < 0.001].

CONCLUSIONS

Early implant exchange results in a reduced subsequent rate of major infectious complications. This protocol reduces the window of time for late infectious complications to develop by proceeding with exchange within 6 weeks of tissue expander placement instead of the standard 6 months, which is common practice. We hypothesize that early exchange allows for washout of the mastectomy cavity, eliminating indolent bacterial contamination that could have subsequently manifested as a late infection. This protocol also obviates the need to operate on patients that undergo post-mastectomy radiotherapy, which also reduces reconstructive failure rates.

The effect of clinical decision making for initiation of systemic anticancer treatments in response to the COVID-19 pandemic in England: a retrospective analysis

Background

Cancer services worldwide had to adapt in response to the COVID-19 pandemic to minimise risk to patients and staff. We aimed to assess the national impact of COVID-19 on the prescribing of systemic anticancer treatment in England, immediately after lockdown and after the introduction of new treatments to reduce patient risk.

Methods

We did a retrospective analysis using data from a central National Health Service England web database mandated for clinicians to register intention to start all new systemic anticancer treatments approved for use in England since 2016. We analysed the monthly number of treatment registrations in April, 2020, after the implementation of societal lockdown on March 23, 2020, and after implementation of treatment options to reduce patient risk such as oral or less immunosuppressive drugs, in May and June, 2020. We compared the number of registrations in April–June, 2020, with the mean number of registrations and SD during the previous 6 months of unaffected cancer care (September, 2019, to February, 2020). We calculated the percentage change and absolute difference in SD units for the number of registrations overall, by tumour type, and by type and line of therapy.

Findings

In April, 2020, 2969 registrations were recorded, representing 1417 fewer registrations than in the control period (monthly mean 4386; 32% reduction, absolute difference 4·2 SDs, p<0·0001). In May, 2020, total registrations increased to 3950, representing a 10% reduction compared with the control period (absolute difference 1·3 SDs, p<0·0001). In June, 2020, 5022 registrations were recorded, representing a 15% increase compared with the control period (absolute difference 1·9 SDs; p<0·0001]).

Interpretation

After the onset of the COVID-19 pandemic, there was a reduction in systemic anticancer treatment initiation in England. However, following introduction of treatment options to reduce patient risk, registrations began to increase in May, 2020, and reached higher numbers than the pre-pandemic mean in June, 2020, when other clinical and societal risk mitigation factors (such as telephone consultations, facemasks and physical distancing) are likely to have contributed. However, outcomes of providing less treatment or delaying treatment initiation, particularly for advanced cancers and neoadjuvant therapies, require continued assessment.

Funding

None.