Treatment delays from transfers of care and their impact on breast cancer quality measures



Despite delays between diagnosis and surgery adversely affecting survival, patients frequently transfer their breast cancer care between institutions. This study was performed to assess the prevalence and effect of such transfers of care (TsOC) on the time to surgery, and its impact on current time-dependent breast cancer quality metrics at Commission on Cancer (CoC) and National Accreditation Program for Breast Centers (NAPBC)-accredited institutions.


Patients having non-metastatic invasive breast cancer diagnosed between 2006 and 2015 at CoC and NAPBC centers (“reporting facilities”) in the National Cancer Database were reviewed. TsOC refer to transferring into or out of a reporting facility between diagnosis and surgery.


Among 622,793 patients, 36.6% of patients transferred care. TsOC add 7.3, 7.8, 8.7, and 9.8 days in time to surgery, chemotherapy, radiotherapy, and endocrine therapy, respectively (p’s < 0.0001). On multivariable analysis, the odds of surgery occurring > 90 days from diagnosis were greatest for patients undergoing unilateral or bilateral mastectomy, Black or Hispanic patients, and those having TsOC (ORs > 1.73, p’s < 0.0001). TsOC increase the odds of non-compliance, per patient, for chemotherapy, radiotherapy and endocrine therapy time-dependent measures by 65.4%, 25.6%, and 56.5%, respectively (p < 0.0001).


TsOC for newly diagnosed breast cancers to or from an accredited facility result in delays in time to surgery which can affect compliance with time-dependent quality measures. Facilities frequently receiving transferred patients may be most adversely affected. Although non-compliance with these quality measures is low, institutions and accrediting bodies should be aware of these associations in order to comply with time-dependent standards.

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The National Cancer Data Base (NCDB) is a joint project of the Commission on Cancer (CoC) of the American College of Surgeons and the American Cancer Society. The CoC’s NCDB and the hospitals participating in the CoC NCDB are the source of the de-identified data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors. Appreciation is extended to Ryan McCabe currently of and Kathleen Thoburn formerly of the American College of Surgeons’ National Cancer Database for their assistance in refining the algorithm for class of case/transfer of care categories utilized herein.

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Correspondence to Richard J. Bleicher.

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All authors declare no conflicts of interest.

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This research was comprised of de-identified database records of human participants, thus maintaining confidentiality and posing negligible or no risks to the participants within the dataset. This article does not contain any studies with animals performed by any of the authors.

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IRB review declared NCDB database review as exempt.

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Bleicher, R.J., Chang, C., Wang, C.E. et al. Treatment delays from transfers of care and their impact on breast cancer quality measures. Breast Cancer Res Treat 173, 603–617 (2019).

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  • Breast cancer
  • Quality measures
  • Delays
  • Transfers of care
  • Second opinions