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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Bleicher RJ, Ruth K, Sigurdson ER et al (2012) Preoperative delays in the US medicare population with breast cancer. J Clin Oncol 30(36):4485–4492
Bleicher RJ, Ruth K, Sigurdson ER et al (2016) Time to surgery and breast cancer survival in the United States. JAMA Oncol 2(3):330–339
American College of Surgeons (2014) National Accreditation Program for Breast Centers. NAPBC Standards Manual 2014 Edition., 2014:77
National Quality Forum. Measures, reports and tools. http://www.qualityforum.org/Measures_Reports_Tools.aspx
Centers for Medicare and Medicaid Services (CMS). Consensus core set: medical oncology measures version 1.0. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/Downloads/Medical-Oncology-Measures.pdf
Churilla TM, Egleston BL, Murphy CT et al (2016) Patterns of multidisciplinary care in the management of non-metastatic invasive breast cancer in the United States Medicare patient. Breast Cancer Res Treat 160(1):153–162
Hillen MA, Medendorp NM, Daams JG et al (2017) Patient-driven second opinions in oncology: a systematic review. Oncologist 22(10):1197–1211
American College of Surgeons. About the National Cancer Database. https://www.facs.org/quality-programs/cancer/ncdb/about
Polverini AC, Nelson RA, Marcinkowski E et al (2016) Time to treatment: measuring quality breast cancer care. Ann Surg Oncol 23(10):3392–3402
Ruetters D, Keinki C, Schroth S et al (2016) Is there evidence for a better health care for cancer patients after a second opinion? A systematic review. J Cancer Res Clin Oncol 142(7):1521–1528
American College of Surgeons. National Accreditation Program for Breast Centers. NAPBC Standards Manual 2018 Edition. (2018). https://accreditation.facs.org/accreditationdocuments/NAPBC/Portal%20Resources/2018NAPBCStandardsManual.pdf:77. https://accreditation.facs.org/accreditationdocuments/NAPBC/Portal%20Resources/2018NAPBCStandardsManual.pdf
Desch CE, McNiff KK, Schneider EC et al (2008) American Society of Clinical Oncology/national comprehensive cancer network quality measures. J Clin Oncol 26(21):3631–3637
Crannell WC, Clark E, Jones C et al (2016) A pattern-matched Twitter analysis of US cancer-patient sentiments. J Surg Res 206(2):536–542
Yen TW, Pezzin LE, Li J et al (2017) Effect of hospital volume on processes of breast cancer care: a National Cancer Data Base study. Cancer 123(6):957–966
Siegel RL, Miller KD, Jemal A (2018) Cancer statistics, 2018. CA Cancer J Clin 68(1):7–30
Boodman SG (2016). Do you need complex surgery? Some doctors may not have much practice. Washington Post
American College of Surgeons. CoC quality of care measures. https://www.facs.org/quality-programs/cancer/ncdb/qualitymeasures
Kaufman CS, Landercasper J (2011) Can we measure the quality of breast surgical care? Ann Surg Oncol 18(11):3053–3060
Tomaszewski JJ, Handorf E, Corcoran AT et al (2014) Care transitions between hospitals are associated with treatment delay for patients with muscle invasive bladder cancer. J Urol 192(5):1349–1354
Recht A, Come SE, Henderson IC et al (1996) The sequencing of chemotherapy and radiation therapy after conservative surgery for early-stage breast cancer. N Engl J Med 334(21):1356–1361
Cold S, During M, Ewertz M et al (2005) Does timing of adjuvant chemotherapy influence the prognosis after early breast cancer? Results of the Danish Breast Cancer Cooperative Group (DBCG). Br J Cancer 93(6):627–632
Hershman DL, Wang X, McBride R et al (2006) Delay in initiating adjuvant radiotherapy following breast conservation surgery and its impact on survival. Int J Radiat Oncol Biol Phys 65(5):1353–1360
Lohrisch C, Paltiel C, Gelmon K et al (2006) Impact on survival of time from definitive surgery to initiation of adjuvant chemotherapy for early-stage breast cancer. J Clin Oncol 24(30):4888–4894
Jara Sanchez C, Ruiz A, Martin M et al (2007) Influence of timing of initiation of adjuvant chemotherapy over survival in breast cancer: a negative outcome study by the Spanish Breast Cancer Research Group (GEICAM). Breast Cancer Res Treat 101(2):215–223
Yu KD, Huang S, Zhang JX et al (2013) Association between delayed initiation of adjuvant CMF or anthracycline-based chemotherapy and survival in breast cancer: a systematic review and meta-analysis. BMC Cancer 13:240
Gagliato Dde M, Gonzalez-Angulo AM, Lei X et al (2014) Clinical impact of delaying initiation of adjuvant chemotherapy in patients with breast cancer. J Clin Oncol 32(8):735–744
Chavez-MacGregor M, Clarke CA, Lichtensztajn DY et al (2016) Delayed Initiation of adjuvant chemotherapy among patients with breast cancer. JAMA Oncol 2(3):322–329
Raphael MJ, Biagi JJ, Kong W et al (2016) The relationship between time to initiation of adjuvant chemotherapy and survival in breast cancer: a systematic review and meta-analysis. Breast Cancer Res Treat 160(1):17–28
Yu KD, Fan L, Qiu LX et al (2017) Influence of delayed initiation of adjuvant chemotherapy on breast cancer survival is subtype-dependent. Oncotarget 8(28):46549–46556
Abdel-Rahman O (2018) Impact of timeliness of adjuvant chemotherapy and radiotherapy on the outcomes of breast cancer; a pooled analysis of three clinical trials. Breast 38:175–180
McGuire KP, Santillan AA, Kaur P et al (2009) Are mastectomies on the rise? A 13-year trend analysis of the selection of mastectomy versus breast conservation therapy in 5865 patients. Ann Surg Oncol 16(10):2682–2690
Balasubramanian BA, Demissie K, Crabtree BF et al (2012) Black Medicaid beneficiaries experience breast cancer treatment delays more frequently than whites. Ethn Dis 22(3):288–294
Wilke LG, Czechura T, Wang C et al (2014) Repeat surgery after breast conservation for the treatment of stage 0 to II breast carcinoma: a report from the National Cancer Data Base, 2004–2010. JAMA Surg 149(12):1296–1305
Loveland-Jones C, Ruth K, Sigurdson ER et al (2012) Breast conservation in the medicare patient: will the american college of surgeons oncology group Z0011 trial change the pattern of care? Ann Surg Oncol 19s1:S64
Bleicher RJ (2018) Timing and delays in breast cancer evaluation and treatment. Ann Surg Oncol. https://doi.org/10.1245/s10434-018-6615-2
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.
Conflict of interest
All authors declare no conflicts of interest.
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.
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). https://doi.org/10.1007/s10549-018-5046-x
- Breast cancer
- Quality measures
- Transfers of care
- Second opinions