Comparison of wait times across the breast cancer treatment pathway among screened women undergoing organized breast assessment versus usual care

OBJECTIVE

The benefit of organized breast assessment on wait times to treatment among asymptomatic women is unknown. The Ontario Breast Screening Program (OBSP) offers screening and organized assessment through Breast Assessment Centres (BAC). This study compares wait times across the treatment pathway among screened women diagnosed with breast cancer through BAC and usual care (UC).

METHODS

A retrospective design identified two concurrent cohorts of postmenopausal women aged 50-69 within the OBSP diagnosed with screen-detected invasive breast cancer and assessed in BAC (n = 2010) and UC (n = 1844) between 2002 and 2010. Demographic characteristics were obtained from the OBSP. Medical chart abstraction provided prognostic and treatment data. Multinomial logistic regression examined associations of assessment type with wait times from abnormal mammogram to surgery, chemotherapy or radiotherapy.

RESULTS

Compared with through UC, postmenopausal women diagnosed through BAC were significantly less likely to have longer wait times (days) from an abnormal mammogram to definitive surgery (> 89 vs. ≤ 47; OR = 0.63; 95% CI = 0.52-0.77), from final surgery to radiotherapy (> 88 vs. ≤ 55; OR = 0.71; 95% CI = 0.54-0.93) and from final chemotherapy to radiotherapy (> 41 vs. ≤ 28; OR = 0.52; 95% CI = 0.36-0.76). Conversely, women assessed through BAC compared with through UC were more likely to experience longer wait times from final surgery to chemotherapy (> 64 vs. ≤ 40; OR = 1.49; 95% CI = 1.04-2.14).

CONCLUSION

Shorter wait times to most treatments for postmenopausal women diagnosed in BAC further supports that women with an abnormal mammogram should be managed through organized assessment. Continued evaluation of factors influencing wait times to treatment is essential for quality improvement and patient outcomes.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Abstract P6-07-01: Are patient perceptions and expectations about peri-operative imaging for metastatic breast cancer in keeping with current guidelines?

Background: The probability of detecting radiologically evident distant metastatic disease in asymptomatic women with primary operable breast cancer is low. Because of this, evidence-based guidelines have been developed to guide physicians on whom to image. Despite these guidelines, peri-operative staging imaging is frequently over-utilized. Relatively little is known about what patients’ perceptions and expectations are regarding peri-operative imaging and whether or not their views are in concordance with the guidelines. We undertook this study in an attempt to answer this question.

Methods: A questionnaire on peri-operative imaging to look for distant metastatic disease was given to women with early stage breast cancer who had completed their surgery. The survey questions were developed in a collaborative effort amongst oncologists, epidemiologists and knowledge translation experts.

Results: Over a 3 month period, 234 surveys were completed at a large Canadian academic cancer centre. The use of peri-operative imaging to assess the skeleton (e.g. bone scan), thorax (e.g. CT, xray), and abdomen (e.g. CT, MRI or ultrasound) is summarized in Table 1 for the 187 patients (80%) who identified their disease stage.

Patient reported perioperative imaging by disease stage Stage 1Stage 2Stage 3No. of patients (%)82/187 (44%)67/187 (36%)38/187 (20%)Median age (range)59 (29-80)57 (27-77)56 (49-65)Peri-operative imaging done for   Skeleton in (%)41/82 (50%)47/67 (70%)33/38 (87%)Thorax in (%)48/82 (59%)53/67 (79%)30/38 (79%)Abdomen in (%)34/82 (41%)42/67 (63%)27/38 (71%)

The relative proportion of patients undergoing imaging increased with advancing stage. Of the 187 patients, 66% indicated they would want imaging if the chance of finding metastatic disease was ≤10% and half of these patients (i.e. 33%) indicated they would want imaging if the chance was <1%. The most common factors identified as being either extremely (EI) or very important (VI) by patients were: catching the spread of cancer to other parts of the body early (93%), reducing the chance of dying (90%), and providing peace of mind (77%). Avoiding inconvenience, exposure to scans, and extra imaging that will not change length or quality of life, and false alarms were EI or VI in ∼50%. Perceptions of these factors did not differ across disease stage. Although 85% indicated doing whatever their doctor recommended was either EI or VI to them, 72% indicated that they would feel very or somewhat uncomfortable if their physician did not order imaging to look for metastatic disease, even if this was in keeping with the guideline recommendation.

Conclusion: Irrespective of evidence-based guidelines, many patients undergo peri-operative imaging. While guidelines tend to address physician behaviour it is evident that patient perceptions and expectations are divergent from the evidence-based guidelines. If patient expectations are, in part, driving excessive imaging, new strategies targeting patient expectations and knowledge are required.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-07-01.