Factors Associated With Delays in Chemotherapy Initiation Among Patients With Breast Cancer at a Comprehensive Cancer Center

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Background: National guidelines endorse time-dependent quality metrics for breast cancer care. We examined factors associated with delays in chemotherapy initiation at an NCI-Designated Comprehensive Cancer Center. Patients and Methods: We identified 523 patients who received postoperative adjuvant chemotherapy between January 2011 and December 2013 at our center. We defined 28 days from last definitive surgery (LDS) to chemotherapy as the target time frame, and an unacceptable delay in chemotherapy initiation (UCD) as greater than 42 days from LDS. Multivariate regression models were used to identify factors associated with UCD and the impact of Oncotype DX testing in patients with hormone receptor (HR)–positive breast cancer. Results: Median days between LDS and chemotherapy initiation was 34 (interquartile range, 15), with 30% of patients starting within 28 days of LDS and 26.9% having UCD. Tumor characteristics such as subtype and stage affected UCD; patients with HR-positive or HER2-positive tumors were more likely to be delayed compared with those with triple-negative breast cancer. Patients with stage I disease, those undergoing mastectomy with or without immediate reconstruction, and those whose pathology sign-out was greater than 10 days postoperatively were more likely to be delayed. A higher proportion of UCD was found in HR-positive patients (31%) for whom Oncotype DX testing was ordered compared with those in whom it was not ordered (20%). Conclusions: This study provides insight into subpopulations that may be at risk to experience delays in chemotherapy initiation, directing interventions to improve the timeliness of care.

Correspondence: Craig A. Bunnell, MD, MPH, MBA, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215. E-mail: craig_bunnell@dfci.harvard.edu
  • 1.

    Allemani C, Weir HK, Carreira H. Global surveillance of cancer survival 1995-2009: analysis of individual data for 25,676,887 patients from 279 population-based registries in 67 countries (CONCORD-2). Lancet 2015;385:9771010.

    • Search Google Scholar
    • Export Citation
  • 2.

    Berry DA, Cronin KA, Plevritis SK. Effect of screening and adjuvant therapy on mortality from breast cancer. N Engl J Med 2005;353:17841792.

    • Search Google Scholar
    • Export Citation
  • 3.

    DeSantis CE, Bray F, Ferlay J. International variation in female breast cancer incidence and mortality rates. Cancer Epidemiol Biomarkers Prev 2015;24:14951506.

    • Search Google Scholar
    • Export Citation
  • 4.

    Saadatmand S, Bretveld R, Siesling S. Influence of tumour stage at breast cancer detection on survival in modern times: population based study in 173,797 patients. BMJ 2015;351:h4901.

    • Search Google Scholar
    • Export Citation
  • 5.

    Berry DA, Cirrincione C, Henderson IC. Estrogen-receptor status and outcomes of modern chemotherapy for patients with node-positive breast cancer. JAMA 2006;295:16581667.

    • Search Google Scholar
    • Export Citation
  • 6.

    Early Breast Cancer Trialists' Collaborative Group (EBCTCG). Effects of chemotherapy and hormonal therapy for early breast cancer on recurrence and 15-year survival: an overview of the randomised trials. Lancet 2005;365:16871717.

    • Search Google Scholar
    • Export Citation
  • 7.

    Chavez-MacGregor M, Clarke CA, Lichtensztajn DY. Delayed initiation of adjuvant chemotherapy among patients with breast cancer. JAMA Oncol 2016;2:322329.

    • Search Google Scholar
    • Export Citation
  • 8.

    Colleoni M, Gelber RD. Time to initiation of adjuvant chemotherapy for early breast cancer and outcome: the earlier, the better? J Clin Oncol 2014;32:717719.

    • Search Google Scholar
    • Export Citation
  • 9.

    Farolfi A, Scarpi E, Rocca A. Time to initiation of adjuvant chemotherapy in patients with rapidly proliferating early breast cancer. Eur J Cancer 2015;51:18741881.

    • Search Google Scholar
    • Export Citation
  • 10.

    Gagliato Dde M, Gonzalez-Angulo AM, Lei X. Clinical impact of delaying initiation of adjuvant chemotherapy in patients with breast cancer. J Clin Oncol 2014;32:735744.

    • Search Google Scholar
    • Export Citation
  • 11.

    Lohrisch C, Paltiel C, Gelmon K. Impact on survival of time from definitive surgery to initiation of adjuvant chemotherapy for early-stage breast cancer. J Clin Oncol 2006;24:48884894.

    • Search Google Scholar
    • Export Citation
  • 12.

    Trufelli DC, de Matos LL, Santi PX. Adjuvant treatment delay in breast cancer patients. Rev Assoc Med Bras 2015;61:411416.

  • 13.

    Yu KD, Huang S, Zhang JX. Association between delayed initiation of adjuvant CMF or anthracycline-based chemotherapy and survival in breast cancer: a systematic review and meta-analysis. BMC Cancer 2013;13:240.

    • Search Google Scholar
    • Export Citation
  • 14.

    Golshan M, Losk K, Kadish S. Understanding process-of-care delays in surgical treatment of breast cancer at a comprehensive cancer center. Breast Cancer Res Treat 2014;148:125133.

    • Search Google Scholar
    • Export Citation
  • 15.

    Senkus E, Kyriakides S, Penault-Llorca F. Primary breast cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2013;24(Suppl 6):vi723.

    • Search Google Scholar
    • Export Citation
  • 16.

    Desch CE, McNiff KK, Schneider EC. American Society of Clinical Oncology/National Comprehensive Cancer Network quality measures. J Clin Oncol 2008;26:36313637.

    • Search Google Scholar
    • Export Citation
  • 17.

    Cold S, During M, Ewertz M. Does timing of adjuvant chemotherapy influence the prognosis after early breast cancer? Results of the Danish Breast Cancer Cooperative Group (DBCG). Br J Cancer 2005;93:627632.

    • Search Google Scholar
    • Export Citation
  • 18.

    Shannon C, Ashley S, Smith IE. Does timing of adjuvant chemotherapy for early breast cancer influence survival? J Clin Oncol 2003;21:37923797.

    • Search Google Scholar
    • Export Citation
  • 19.

    Bleicher RJ, Ruth K, Sigurdson ER. Time to surgery and breast cancer survival in the United States. JAMA Oncol 2016;2:330339.

  • 20.

    Liederbach E, Sisco M, Wang C. Wait times for breast surgical operations, 2003-2011: a report from the National Cancer Data Base. Ann Surg Oncol 2015;22:899907.

    • Search Google Scholar
    • Export Citation
  • 21.

    Vandergrift JL, Niland JC, Theriault RL. Time to adjuvant chemotherapy for breast cancer in National Comprehensive Cancer Network institutions. J Natl Cancer Inst 2013;105:104112.

    • Search Google Scholar
    • Export Citation
  • 22.

    Alderman AK, Collins ED, Schott A. The impact of breast reconstruction on the delivery of chemotherapy. Cancer 2010;116:17911800.

  • 23.

    Barry PN, Riley EC, Pan J. Delay of adjuvant chemotherapy after elective mastectomy and immediate reconstruction in breast-conservation candidates: a matched-pair analysis. Am J Clin Oncol 2014;37:575579.

    • Search Google Scholar
    • Export Citation
  • 24.

    Fedewa SA, Ward EM, Stewart AK. Delays in adjuvant chemotherapy treatment among patients with breast cancer are more likely in African American and Hispanic populations: a national cohort study 2004-2006. J Clin Oncol 2010;28:41354141.

    • Search Google Scholar
    • Export Citation
  • 25.

    Freedman RA, He Y, Winer EP. Racial/Ethnic differences in receipt of timely adjuvant therapy for older women with breast cancer: are delays influenced by the hospitals where patients obtain surgical care? Health Serv Res 2013;48:16691683.

    • Search Google Scholar
    • Export Citation
  • 26.

    Lee J, Lee SK, Kim S. Does immediate breast reconstruction after mastectomy affect the initiation of adjuvant chemotherapy? J Breast Cancer 2011;14:322327.

    • Search Google Scholar
    • Export Citation
  • 27.

    Sharpe SM, Liederbach E, Czechura T. Impact of bilateral versus unilateral mastectomy on short term outcomes and adjuvant therapy, 2003-2010: a report from the National Cancer Data Base. Ann Surg Oncol 2014;21:29202927.

    • Search Google Scholar
    • Export Citation
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