Abstract P5-13-15: Process-of-care: Elucidating delays in surgical treatment of breast cancer
Authors: Golshan M , Weingart SN , Losk K , Hirshfield-Bartek J , Cutone L , Abeita J , Kadish S , Bunnell C 
Published: August 2014

Abstract
Background: We examined the timeliness of breast cancer care at our cancer center, focusing on care processes that affect the time from surgical consultation to surgery, with the goal of identifying improvement opportunities.
Methods: We studied 584 women who underwent a mastectomy (with or without reconstruction) or breast conserving therapy at one of two Dana-Farber/Brigham and Women's Cancer Center (DF/BWCC) surgical sites between Jan. 1, 2011 and Feb. 28, 2012. We excluded patients who received a DF/BWCC consultation but received surgery elsewhere, those who required neo-adjuvant chemotherapy, and patients whose surgeons had no primary appointment at DF/BWCC.
We calculated the delay between consultation and surgery, defined as an interval of greater than two weeks for cases of mastectomy without reconstruction or breast conserving therapy, and four weeks for those with mastectomy with immediate reconstruction. We tabulated the number of patients with a delay, stratified by type of procedure and patient characteristics. We examined factors associated with a delay in bivariate analyses using Chi-square and multivariate logistic regression models with two-tailed tests and p&lt;0.05. We examined provider-level variation in a subset of reconstructive surgery cases, and reviewed medical records of 50 patients with the greatest delays.
Results. The mean number of days from consultation to surgery was 21 (range 2-104, SD 14) for lumpectomy, 31 (5-230, 28) for mastectomy, and 41 (6-180, 26) for mastectomy with reconstruction. Of women undergoing breast conserving therapy or mastectomy without reconstruction, 296 (67%) experienced a delay compared to 102 (71%) undergoing mastectomy with immediate reconstruction. Although no statistically significant findings were obtained in the bivariate analyses, age over 60 was associated with a two-fold delay in the multivariable model. Delays were also more likely among mastectomy procedures compared to breast conserving therapy.
TableCharacteristicsNo Delay (n = 186)Delay (n = 398)OR (95% CI) No. (%)No. (%) Age 70-9528 (15)69 (17)2.6 (1.3-5.5)60-6943 (23)107 (27)2.0 (1.2-3.6)50-5951 (27)103 (26)1.3 (0.8-2.0)18-4964 (34)119 (30)1.0Race Non-White21 (11)43 (11)1.0 (0.6-1.9)White161 (89)346 (89)1.0Missing49 Primary Language Non-English7 (4)14 (4)1.0 (0.4-2.9)English179 (96)384 (97)1.0Insurance Medicare49 (26.3)97 (24)0.6 (0.3-1.0)Medicaid6 (3)8 (2)0.6 (0.2-1.7)Private131 (70)292 (74)1.0Missing01 Procedure Mastectomy with Recon41 (22)102 (26)1.6 (1.0-2.5)Mastectomy without Recon15 (8.1)53 (13)1.9 (1.0-3.6)Lumpectomy130 (70)243 (61)1.0
The 4 highest-volume breast surgeons (n&gt;20 procedures each) varied in the time from initial consultation to plastic surgery consultation, from a mean of 7 to 22 days. Early screening and referral practices accounted for much of this variation. Delayed surgeries among the 50 patients with delays of at least 45 days included the need for additional testing or imaging, pre-operative medical evaluation, or “personal” reasons.
Conclusion. Analyses of the interval from consultation to breast surgery identified process variation that may be amenable to improvement initiatives. Cancer centers should invest in efforts to measure, monitor, and improve the timeliness of breast cancer care.
Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P5-13-15.