A3 – Time to surgery after a diagnosis of breast cancer

A3 – Time to surgery after a diagnosis of breast cancer   

Key Messages

•   Across the RCN, it takes on average almost 8 weeks from the date of a biopsy diagnosing breast cancer to the date of the surgery (lumpectomy or mastectomy).

•  MUHC and the JGH have longer delays to surgery, with a median time to delay of 7.1 weeks and 9.0 weeks respectively. SMHC has the shortest median delay at 5.3 weeks.

•  Longer delays are seen at the RCN partner hospitals that perform more breast cancer surgeries per year. For example, in fiscal year 2016, the JGH and the MUHC each performed over 400 breast cancer surgeries, while SMHC performed less than 200 breast cancer surgeries.  


Background

To evaluate a suspicious mass observed on imaging or by palpation, a needle biopsy is commonly performed. If the diagnosis is breast cancer, most women will have some type of surgery as part of their treatment. Sometimes chemotherapy is given before surgery (neoadjuvant treatment) but more usually surgery is the first treatment.

Surgical delays can cause anxiety for the patient and longer time to surgery has recently been shown to affect survival for early stage breast cancer.1 Surgical delays also have the potential to delay post-operative chemotherapy or radiation therapy. Avoiding delays in breast cancer care is important to ensure the best possible outcomes.1,2,3

There is no consensus as to what constitutes an acceptable surgical delay after a diagnosis of breast cancer.3 Recent data show that for every 60-day increase in time from biopsy to surgery, there is added risk of death due to breast cancer. As shown in a typical care pathway for breast cancer patients, the RCN measures two indicators pertaining to surgical delays. Indicator A1, which is reported monthly by the Ministry of Health and Social Services (MSSS), is calculated from the time the procedure is requested by the surgeon to the time surgery is performed. The Quebec government target for surgical wait time for patients with cancer is that 90% of patients should have their surgery performed within 28 days of the surgeon requesting the surgery. Indicator A3 represents the delay from the biopsy confirming breast cancer to the date of surgery. Although there is no definite target for this delay, the Breast Disease site group based on recent data1, recommends that surgeries be performed within 60 days of biopsy for the majority of patients.

Measuring variations in surgical wait times across the RCN can help to gauge how well the cancer system is working and to raise awareness of the importance of timely care.

What Do the Results Mean?

The data show that the median time from biopsy to breast cancer surgery for patients across the RCN is 53 days (7.6 weeks). This means that 50% of patients will have their surgery within 53 days of the date of a definitive biopsy indicating breast cancer. Almost all patients (90% of patients) diagnosed with breast cancer will have their surgery done within 86 days (12.3 weeks) of their biopsy. Patients who receive chemotherapy before surgery are not included in this analysis.

Patients treated at the MUHC and JGH wait longer on average for their surgery (52.5 days and 62.3 days respectively) than patients having surgery at SMHC (41.4 days).

Many factors may affect treatment delays, such as:

•  need for additional imaging studies (e.g., MRI) or genetic testing

•  delay in patient referral to a specialist surgeon

•  time for the biopsy pathology report confirming the diagnosis

•  case presentation at a multidisciplinary Cancer Diagnosis and Treatment Committee (CDTC)

•  limitation of hospital (e.g., surgeon capacity (lack of operating time) or availability of recovery beds)

•  severity of the disease or type of surgery (e.g., breast reconstruction at the same time as the initial cancer surgery requires the availability of two surgical specialists and so typically incurs more delays)

•  patient preferences, such as the desire to obtain second opinions or requiring more time to make a decision when a treatment choice exists

While indicator A3 is a more relevant measure of the surgical delay, indicator A1 allows comparisons to be easily made across institutions in Quebec and Canada. It is reported monthly and monitored by the institutions and the MSSS. 

Efforts in this Area

Reducing surgical delays for cancer patients is a priority of RCN partner hospitals and of the Ministry of Health and Social Services (see indicator A1). Any improvements in these delays will also lead to overall improvements in delays from biopsy to surgery.

The Breast Disease Site Group aims to standardize the trajectory from diagnosis to surgery for breast cancer patients so that delays are reduced. They are focusing their attention on standardizing pre-operative imaging workup and surgical approach. 

Notes

Data Specifications

DEFINITION    

Time (days) from diagnostic biopsy to initial breast surgery for patients with breast cancer

SOURCE    

Cancer registry

CALCULATIONS    

Wait time =  [date of initial breast cancer surgery] – [date of diagnostic biopsy] 

EXCLUSIONS   

Breast cancer patients who received intravenous chemotherapy before surgery (neoadjuvant treatment)

Breast cancer patients with delays > 120 days as these patients likely received other treatments (ex. oral neoadjuvant treatment)

Breast cancer patients who underwent a surgical procedure without obtaining a prior diagnostic biopsy (ex. Excisional biopsy)

Breast cancer patients having undergone a surgical procedure without a known biopsy date

MEASUREMENT TIMEFRAME    

Annually, by fiscal year (April to March). Data for two fiscal years is shown (2014-15 and 2015-16). 

NOTES    

The wait times are associated to the hospital where the surgery was performed. The biopsy could have been performed elsewhere.

If a patient had multiple biopsies, the wait time was calculated using the biopsy closest to the surgery date.

For patients with more than one surgery, only the initial surgery was considered.

References

1. Bleicher RJ, Ruths K, Sigurdson ER et al. Time to surgery and breast cancer survival in the United States. JAMA Oncol. 2016;2(3):330-339.

 2. Colleoni M, Bonetti M, Coates AS, et al. Early start of adjuvant chemotherapy may improve treatment outcome for premenopausal breast cancer patients with tumors not expressing estrogen receptors. The International Breast Cancer Study Group. J Clin Oncol. 2000;18:584–90.

3. Shin DW, Cho J, Kim SY, et al. Delay to curative surgery greater than 12 weeks is associated with increased mortality in patients with colorectal and breast cancer but not lung or thyroid cancer. Ann Surg Oncol. 2013;20(8):2468-2476.

Disclaimer: The Rossy Cancer Network has attempted to ensure the accuracy of the data that it is reporting for each of its hospitals. Values posted on this web page may change as new information becomes available or corrections are made; this may alter accumulated values.

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