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

  • Epidemiology
  • Published:
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Abstract

Purpose

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.

Methods

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).

Results

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).

Conclusions

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.

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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.

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Funding

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.

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Authors and Affiliations

  1. Department of Surgery, Duke University Medical Center, Box 3513, Durham, NC, 27710, USA

    Ipshita Prakash, Rachel A. Greenup, Jennifer K. Plichta, Laura H. Rosenberger & Oluwadamilola M. Fayanju

  2. Biostatistics Shared Resource, Duke Cancer Institute, Durham, NC, 27710, USA

    Samantha M. Thomas & Terry Hyslop

  3. Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, 27710, Box 2717, USA

    Samantha M. Thomas & Terry Hyslop

  4. Duke Cancer Institute, Women’s Cancer Program, Durham, NC, 27710, USA

    Rachel A. Greenup, Jennifer K. Plichta, Laura H. Rosenberger & Oluwadamilola M. Fayanju

  5. Department of Population Health Sciences, Duke University School of Medicine, 215 Morris Street, Durham, NC, 27701, USA

    Rachel A. Greenup & Oluwadamilola M. Fayanju

  6. Duke Margolis Center for Health Policy, Durham, NC, USA

    Rachel A. Greenup

  7. Department of Surgery, Duke Regional Hospital, 3643 N. Roxboro Street, Durham, NC, 27704, USA

    Laura H. Rosenberger

  8. Duke Forge, Duke University, Durham, NC, 27710, USA

    Oluwadamilola M. Fayanju

  9. Department of Surgery, Durham VA Medical Center, 508 Fulton St, Durham, NC, 27705, USA

    Oluwadamilola M. Fayanju

  10. Department of Surgery, Glen Campus, Royal Victoria Hospital, McGill University Health Centre, 1001 Blvd Decarie, Montreal, QC, Canada

    Ipshita Prakash

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  1. Ipshita Prakash
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  7. Oluwadamilola M. Fayanju
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Corresponding author

Correspondence to Oluwadamilola M. Fayanju.

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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.

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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). https://doi.org/10.1007/s10549-020-06012-7

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  • DOI: https://doi.org/10.1007/s10549-020-06012-7

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