Timeliness for Surgery in Breast Cancer Care

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • The management of breast cancer:
    • Has become increasingly complex and multidisciplinary:
      • With increasing imaging studies, appointments, and often, second or third opinions patients seek for care
    • Together, many of these factors have led to lengthening time intervals between diagnosis and surgery
  • At the same time, time from diagnosis to surgical treatment of 60 days:
    • Is now a Commission on Cancer quality metric
  • Minimizing delays in treatment:
    • Is a sensible goal believed to lead to improved outcomes
  • The precise time frame that is considered reasonable and safe versus detrimental to breast cancer survival is not known:
    • Although a number of recent large retrospective studies have evaluated this
  • Bleicher et al:
    • In a 2016 study of nearly 100,000 women > age 65 in the SEER-Medicare database:
      • Showed that overall survival decreased by 9% after a 60-day delay from diagnosis to surgery
    • In addition, the association between overall survival and time to surgery:
      • Was significant for stage I (HR 1.13, p<0.001) and stage II (HR 1.06, p<0.01):
        • But not for stage III breast cancer patients
    • The association between breast cancer-specific survival and time to surgery (HR 1.84, p=0.02):
      • Persisted solely for stage I patients:
        • Likely attributable to the baseline mortality in this group being smaller than the relative impact imposed by a delay in treatment
  • A 2020 study of ~350,000 patients (of all ages) in the NCDB with stage I to III breast cancer treated with up front surgical therapy examined the relationship between overall survival, time to surgery, and biologic subtype of breast cancer (i.e. triple negative, ER+PR+, HER2+):
    • Prevailing opinion prior to this study was that delays would be more detrimental to those with more biologically aggressive tumors such as TN or HER2+ due to downstream delays in adjuvant systemic therapy resulting from delayed surgical treatment
    • This study found that overall survival was observed to decline with every month delay in surgical treatment (HR 1.1, p<0.001), and this did not vary by biologic subtype (p>0.33)
  • A more recent 2023 study of NCDB stage I to III breast cancer patients treated with up front surgery analyzed survival for every one-week interval after 30 days post-diagnosis:
    • Median time to surgery was 30 days:
      • 90% of patients underwent surgery within 60 days
    • Delays of 9 weeks or greater:
      • Were found to be more common in younger women and the uninsured
    • They found that there was no significant association between time to surgery and survival:
      • For any of the groups until after 9 weeks post-diagnosis
    • A surgical delay of 9 weeks or longer after diagnosis was associated with worse overall survival (HR 1.15, p < 0.001) compared with surgery within 4 weeks of diagnosis
    • Again, no significant interaction was found between tumor biologic subtype and time to surgery’s association with survival
    • Therefore, the conclusion was made that 8 weeks or shorter serve as a standard quality metric for timeliness of surgery
  • References:
    • Bleicher RJ et al. Preoperative delays in the US Medicare population with breast cancer. J Clin Oncol 2012; 30:4485-92
    • Bleicher RJ et al. Time to Surgery and Breast Cancer Survival in the United States. JAMA Surg 2016; 2:330-9
    • Mateo AM et al. Time to Surgery and the Impact of Delay in the Non-Neoadjuvant Setting on Triple-Negative Breast Cancers and Other Phenotypes. Ann Surg Oncol 2020; 27:1679-92
    • Wiener AA et al. Reexamining Time From Breast Cancer Diagnosis to Primary Breast Surgery. JAMA Surg 2023; 158:485-92
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Published by Rodrigo Arrangoiz MS, MD, FACS, FSSO

My name is Rodrigo Arrangoiz I am a breast surgeon/ thyroid surgeon / parathyroid surgeon / head and neck surgeon / surgical oncologist that works at Center for Advanced Surgical Oncology in Miami, Florida. I was trained as a surgeon at Michigan State University from (2005 to 2010) where I was a chief resident in 2010. My surgical oncology and head and neck training was performed at the Fox Chase Cancer Center in Philadelphia from 2010 to 2012. At the same time I underwent a masters in science (Clinical research for health professionals) at the University of Drexel. Through the International Federation of Head and Neck Societies / Memorial Sloan Kettering Cancer Center I performed a two year head and neck surgery and oncology / endocrine fellowship that ended in 2016. Mi nombre es Rodrigo Arrangoiz, soy cirujano oncólogo / cirujano de tumores de cabeza y cuello / cirujano endocrino que trabaja Center for Advanced Surgical Oncology en Miami, Florida. Fui entrenado como cirujano en Michigan State University (2005 a 2010 ) donde fui jefe de residentes en 2010. Mi formación en oncología quirúrgica y e n tumores de cabeza y cuello se realizó en el Fox Chase Cancer Center en Filadelfia de 2010 a 2012. Al mismo tiempo, me sometí a una maestría en ciencias (investigación clínica para profesionales de la salud) en la Universidad de Drexel. A través de la Federación Internacional de Sociedades de Cabeza y Cuello / Memorial Sloan Kettering Cancer Center realicé una sub especialidad en cirugía de cabeza y cuello / cirugia endocrina de dos años que terminó en 2016.

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