Race of the Clock: Reducing Delay to Curative Breast Cancer Surgery

Methods

The team used data from the Moffitt Cancer Center tumor registry, the patient appointment system, breast cancer surgery database, breast cancer tumor board, and the NCCN Oncology Outcomes Database for Breast Cancer for patients diagnosed with stage 0-III breast cancer in 2010 for this study. Benchmark comparison data from institutions participating in the outcomes database for breast cancer were also available.

Analytic cases in the cancer registry involved patients with breast cancer who were diagnosed or received all or part of their first treatment course at Moffitt Cancer Center. Patients who underwent breast reconstruction were also identified. Type of reconstruction was analyzed based on immediate or delayed procedures.

Lead time from breast cancer diagnosis by needle biopsy to first definitive surgery was analyzed to determine causes for potential delays. Three phases of the process were identified: biopsy to date of first consult (BX-FC); first consult to date of tumor board (FC-TB); and tumor board to date of surgery (TB-SU). Potential contributing factors, including operating room capacity and schedules, were also examined to evaluate their effect on specific steps in the process. The Moffitt Cancer Center Process Excellence team assisted in collecting and analyzing the information.

Results

Findings showed that 52% of the total lead time was spent in the TB-SU phase, with 35% in the BX-FC and 13% in the FC-TB phases. Average lead time and variation in duration of lead time of 3.6 weeks (standard deviation [SD], 2.2 weeks) was longest for the TB-SU phase compared with 2.4 (SD, 1.6 weeks) and 0.9 weeks in the BX-FC and FC-TB phases, respectively. Additionally, 35% of the cases involved coordination of surgery schedules between breast surgical oncology and plastic surgery, which added an average of 1 week to the TB-SU phase. Patients who elected immediate reconstruction averaged 4 days longer lead time than those without immediate reconstruction.

Stage III cases had the longest average total lead time of 8.8 weeks compared with mean total lead times for stages I and II of 6.6 and 6.9 weeks, respectively. Additionally, TB-SU phase times were approximately 2.4 weeks longer when surgery was scheduled after TB (7.5 weeks) compared with before TB (5.1 weeks). Additionally, 38% of surgeries were booked less than 2 weeks before surgery and 46% within 2 to 4 weeks. The likelihood of surgery scheduled within 2 weeks decreased significantly if the patient required breast reconstruction, from 46% without plastic surgery to 15% with plastic surgery.

Analysis of additional lead time measures showed no significant differences among breast surgeons or in cases from outside the 7-county region. The average lead time was 6 days from FC-TB for all case types, and 2% of cases were presented at TB more than once. For biopsies, 19% were completed at Moffitt Cancer Center. A total of 33% of patients had Medicare or Medicaid coverage, which added approximately 1 week lead time.

Because the TB-SU phase showed the greatest lead time variation, further analysis was conducted to determine operating room (OR) use, capacity, scheduling, policies, and processes that could affect this outcome. The average OR use by the breast program was 74%, with an average block use by surgeon of 88%, indicating potential capacity for additional cases with assigned blocks. Of overall surgery time, 12% occurred outside the scheduled block, and interviews with individual surgeons revealed that the lengths of assigned blocks did not accommodate certain procedures. Furthermore, high OR use and the need to coordinate between schedules for breast surgical oncologists and plastic surgeons created difficulty in booking concurrent cases. Scheduled duration versus actual surgery time was also analyzed to determine the accuracy of scheduled surgery time. Of scheduled procedures, 83% were completed within 60 minutes of the scheduled time. The average OR capacity across all programs was also 83%, indicating some, but limited, capacity for additional cases.

Discussion

The OFI project provided a tremendous opportunity to develop insight into breast program processes to streamline care of patients with breast cancer. As a result of the analysis, all new patients are offered an appointment for first consultation within 7 days of request. The greatest opportunity for improvement was in the TB-SU time frame. Due to the high volume of breast cancer cases for surgical treatment and the complexity of schedules, especially for immediate breast reconstruction, a substantial amount of the time surgeons spend in the OR occurs outside their assigned block schedule. This constrains the capacity of the breast surgeons and plastic surgeons, and is the primary root cause of delay.

Analysis revealed a need for additional surgical faculty, and recruitment is currently underway. An additional plastic surgeon joined the faculty this year, and another mid-level practitioner was hired for support. An emphasis has been placed on fine-tuning scheduling, especially in the TB-SU phase. Steps have also been taken to decrease the interval from abnormal diagnostic imaging result to biopsy. This helps decrease patient anxiety and improve patient satisfaction.

Patient demographics, such as age, ethnic background, race, medical insurance coverage, and geographic area, have also been related to delay in surgical treatment of breast cancer.^7,8 These factors provide the opportunity for further institutional study.

Finally, Moffitt Cancer Center is expanding the physical outpatient facilities of the breast program, which should dramatically improve times for all phases. The multiphase project includes a new 7-story, 200,000-square-foot building. The breast program will be housed in the new structure, which will allow for a higher capacity for patients with breast cancer and expanded services, including an ambulatory surgery center and procedure suites. The new facility is anticipated to be operational in early 2015.