Skip to main content


Log in

Time to surgery among women treated with neoadjuvant systemic therapy and upfront surgery for breast cancer

  • Epidemiology
  • Published:
Breast Cancer Research and Treatment Aims and scope Submit manuscript



Time to surgery (TTS) is a potentially modifiable factor associated with survival after breast cancer diagnosis and can serve as a proxy for quality of oncologic care coordination. We sought to determine whether factors associated with delays in TTS vary between patients who receive neoadjuvant systemic therapy (NST) vs upfront surgery and whether the impact of these delays on overall survival (OS) varies with treatment sequence.


Women ≥ 18 years old with Stage I–III breast cancer were identified in the National Cancer Database (2004–2014). Multivariate linear regression stratified by treatment sequence (upfront surgery vs NST [neoadjuvant chemotherapy {NAC}, neoadjuvant endocrine therapy {NAE}, or both {NACE}]) was used to identify factors associated with TTS. Cox proportional hazards models were used to estimate the effect of TTS on overall survival (OS).


Of 693,469 patients, 14.8% (n = 102,326) received NST (NAC n = 85,143, NAE n = 10,004, NACE n = 7179). Non-White race/ethnicity, no or government-issued insurance, more extensive surgery (i.e., mastectomy and contralateral prophylactic mastectomy vs breast-conserving surgery), and post-mastectomy reconstruction were associated with significantly longer adjusted TTS for NAC and upfront-surgery recipients, but only upfront-surgery patients had progressively worse OS with increasing TTS (> 180 vs ≤ 30 days: HR = 1.31, all p < 0.001).


Surgery extent, race/ethnicity, and insurance were associated with TTS across treatment groups, but longer TTS was only associated with worse OS in upfront-surgery patients. Our findings can help inform surgeon–patient communication, shared decision making, care coordination, and patients’ expectations throughout both NST and in the perioperative period.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2

Similar content being viewed by others

Data availability

The data that support the findings of this study are available from the National Cancer Database (NCDB) but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are, however, available from the authors upon reasonable request and with permission of the NCDB.


  1. Siu AL (2016) Force USPST screening for breast cancer: U.S. preventive services task force recommendation statement. Ann Intern Med. 164:279–296

    Article  Google Scholar 

  2. Hendrick RE, Baker JA, Helvie MA (2019) Breast cancer deaths averted over 3 decades. Cancer 125(9):1482–1488

    Article  Google Scholar 

  3. Canadian Task Force On Preventive Health Care, Tonelli M, Connor GS, et al. Recommendations on screening for breast cancer in average‐risk women aged 40–74 years. CMAJ 2011; 183:1991–2001.

  4. Rosselli Del Turco M, Ponti A, Bick U et al (2010) Quality indicators in breast cancer care. Eur J Cancer 46(13):2344–2356

    Article  Google Scholar 

  5. Wagner JL, Warneke CL, Mittendorf EA et al (2011) Delays in primary surgical treatment are not associated with significant tumor size progression in breast cancer patients. Ann Surg 254(1):119–124

    Article  Google Scholar 

  6. Brazda A, Estroff J, Euhus D et al (2010) Delays in time to treatment and survival impact in breast cancer. Ann Surg Oncol 17(Suppl 3):291–296

    Article  Google Scholar 

  7. Neal RD, Tharmanathan P, France B et al (2015) Is increased time to diagnosis and treatment in symptomatic cancer associated with poorer outcomes? Systematic review Br J Cancer 112(Suppl 1):92–107

    Article  Google Scholar 

  8. Eaglehouse YL, Georg MW, Shriver CD et al (2019a) Time-to-surgery and overall survival after breast cancer diagnosis in a universal health system. Br Cancer Res Treat 178(2):441–450

    Article  Google Scholar 

  9. 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

    Article  Google Scholar 

  10. Smith EC, Ziogas A, Anton-Culver H et al (2013) Delay in surgical treatment and survival after breast cancer diagnosis in young women by race/ethnicity. JAMA Surg 148(6):516–523

    Article  Google Scholar 

  11. Eaglehouse YL, Georg MW, Shriver CD et al (2019b) Racial differences in time to breast cancer surgery and overall survival in the US military health system. JAMA Surg 154(3):e185113

    Article  Google Scholar 

  12. Solomon M, Cochrane CT, Grieve DA et al (2015) Insurance status and time to completion of surgery for breast cancer. ANZ J Surg 86(1–2):84–87

    PubMed  Google Scholar 

  13. Landercasper J, Linebarger JH, Ellis RL et al (2010) A quality review of the timeliness of breast cancer diagnosis and treatment in an integrated breast center. J Am Coll Surg 210(4):449–455

    Article  Google Scholar 

  14. Murphy BL, Day CN, Hoskin TL et al (2018) Neoadjuvant chemotherapy use in breast cancer is greatest in excellent responders: triple-negative and HER2+ subtypes. Ann Surg Oncol 25(8):2241–2248

    Article  Google Scholar 

  15. American College of Surgeons. National Cancer Database. 1996–2016 [cited January 22, 2020]. Available at:

  16. Jagsi R, Jiang J, Momoh AO et al (2014) Trends and variation in use of breast reconstruction in patients with breast cancer undergoing mastectomy in the United States. J Clin Oncol 32(9):919–926

    Article  Google Scholar 

  17. Cemal Y, Albornoz CR, Disa JJ et al (2013) A paradigm shift in the U.S. breast reconstruction part 2 The influence of changing mastectomy patterns on reconstructive rate and method. Plast Reconstr Surg. 131(3):320e–326e

    Article  CAS  Google Scholar 

  18. Jabo B, Lin AC, Aljehani MA et al (2018) Impact of breast reconstruction on time to definitive surgical treatment, adjuvant therapy, and breast cancer outcomes. Ann Surg Oncol 25(10):3096–3105

    Article  Google Scholar 

  19. Omarini C, Guaitoli G, Noventa S et al (2017) Impact of time to surgery after neoadjuvant chemotherapy in operable breast cancer patients. Eur J Surg Oncol 43(4):613–618

    Article  CAS  Google Scholar 

  20. Sanford RA, Lei X, Barcenas CH et al (2016) Impact of time from completion of neoadjuvant chemotherapy to surgery on survival outcomes in breast cancer patients. Ann Surg Oncol 23(5):1515–1521

    Article  Google Scholar 

  21. Suleman K, Almalik O, Haque E et al. Does the timing of surgery after neoadjuvant therapy in breast cancer patients affect the outcome? Oncology. 2020; 1–6.

  22. Fisher B, Brown A, Mamounas E et al (1997) Effect of preoperative chemotherapy on local-regional disease in women with operable breast cancer: findings from National Surgical Adjuvant Breast and Bowel Project B-18. J Clin Oncol 15(7):2483–2493

    Article  CAS  Google Scholar 

  23. Van der Hage JA, Van de Velde CJ, Julien JP et al (2001) Preoperative chemotherapy in primary operable breast cancer: results from the European organization for research and treatment of cancer trial 10902. J Clin Oncol 19:4224–4237

    Article  Google Scholar 

  24. Rastogi P, Anderson SJ, Bear HD et al (2008) Preoperative chemotherapy: updates of national surgical adjuvant breast and bowel project protocols B-18 and B-27. J Clin Oncol 26(5):778–785

    Article  Google Scholar 

  25. Cortazar P, Zhang L, Untch M et al (2014) Pathological complete response and long-term clinical benefit in breast cancer: the CTNeoBC pooled analysis. Lancet 384:164–172

    Article  Google Scholar 

  26. Boughey JC, McCall LM, Ballman KV et al (2014) Tumor biology correlates with rates of breast-conserving surgery and pathologic complete response after neoadjuvant chemotherapy for breast cancer: findings from the ACOSOG (Alliance) Z1071 Prospective Multicenter Clinical Trial. Ann Surg 260:608–614

    Article  Google Scholar 

  27. Fayanju OM, Ren Y, Thomas SM et al (2018) The clinical significance of breast-only and node-only pathologic complete response (pCR) after neoadjuvant chemotherapy (NACT): a review of 20,000 breast cancer patients in the National Cancer Data Base (NCDB). Ann Surg 268(4):591–601

    Article  Google Scholar 

  28. Von Minckwitz G, Untch M, Blohmer JU et al (2012) Definition and impact of pathologic complete response on prognosis after neoadjuvant chemotherapy in various intrinsic breast cancer subtypes. J Clin Oncol 30(15):1796–1804

    Article  Google Scholar 

  29. Spring LM, Gupta A, Reynolds KL et al (2016) Neoadjuvant endocrine therapy for estrogen-receptor-positive breast cancer: a systematic review and meta-analysis. JAMA Oncol 2(11):1477–1486

    Article  Google Scholar 

  30. Balic M, Thomssen C, St WR, Gallen V et al (2019) a brief summary of the consensus discussion on the optimal primary breast cancer treatment. Breast Care 2019(14):103–110

    Article  Google Scholar 

  31. Barroso-Sousa R, Silva DD, Alessi JV et al (2016) Neoadjuvant endocrine therapy in breast cancer: current role and future perspectives. Ecancermedicalscience 10:609.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Andersen BL, Cacioppo JT (1995) Delay in seeking a cancer diagnosis: delay stages and psychophysiological comparison processes. The British journal of social psychology 34(1):33–52

    Article  Google Scholar 

  33. Walter F, Webster A, Scott S, Emery J (2012) The Andersen Model of Total Patient Delay: a systematic review of its application in cancer diagnosis. J Health Serv Res Policy 17(2):110–118

    Article  Google Scholar 

  34. Gooiker GA, van Gijn W, Post PN, van de Velde CJ, Tollenaar RA, Wouters MW (2010) A systematic review and meta-analysis of the volume-outcome relationship in the surgical treatment of breast cancer Are breast cancer patients better of with a high volume provider? Eur J Surg Oncol. 36(1):S27-35

    Article  Google Scholar 

  35. Greenup RA, Obeng-Gyasi S, Thomas S et al (2018) The effect of hospital volume on breast cancer mortality. Ann Surg 267:375–381

    Article  Google Scholar 

  36. Reeder-Hayes KE, Anderson BO (2017) Breast cancer disparities at home and abroad: a review of the challenges and opportunities for system-level change. Clin Cancer Res 23(11):2655–2664

    Article  Google Scholar 

  37. Sheppard VB, Oppong BA, Hampton R et al (2015) Disparities in breast cancer surgery delay: the lingering effect of race. Ann Surg Oncol 22(9):2902–2911

    Article  Google Scholar 

  38. Tammemagi CM (2007) Racial/ethnic disparities in breast and gynecologic cancer treatment and outcomes. Curr Opin Obstet Gynecol 19:31–36

    Article  Google Scholar 

  39. Shaves VL, Brown ML (2002) Racial and ethnic disparities in the receipt of cancer treatment. J Natl Cancer Inst 94:332–357

    Article  Google Scholar 

  40. Sutton TL, Schlitt A, Gardiner SK, Johnson N, Garreau JR. Time to Surgery Following Neoadjuvant Chemotherapy for Breast Cancer Impacts Residual Cancer Burden, Recurrence, and Survival. Society of Surgical Oncology (SSO) International Conference on Surgical Cancer; 2020.

Download references


Dr. Fayanju is supported by the National Institutes of Health (NIH) under Award Number 1K08CA241390 (PI: Fayanju). This work is also supported by the Duke Cancer Institute through NIH grant P30CA014236 (PI: Kastan). The content of this manuscript is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

Author information

Authors and Affiliations


Corresponding author

Correspondence to Oluwadamilola M. Fayanju.

Ethics declarations

Conflicts of interest

Ipshita Prakash, Rachel A. Greenup, Jennifer K. Plichta, Laura H. Rosenberger, and Oluwadamilola M. Fayanju declare that they have no conflicts of interest to disclose. Samantha M. Thomas and Terry Hyslop were previously consultants for AbbVie.

Ethical approval

This retrospective study involving de-identified data from human participants was conducted in accordance with the ethical standards of the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The institutional review board (IRB) at Duke University determined that our study did not need ethical approval, and our study was granted exempt status with a waiver of informed consent.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 45 KB)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Prakash, I., Thomas, S.M., Greenup, R.A. et al. Time to surgery among women treated with neoadjuvant systemic therapy and upfront surgery for breast cancer. Breast Cancer Res Treat 186, 535–550 (2021).

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: