Time interval from diagnosis to treatment of breast cancer at an NCI Comprehensive Cancer Center: Survival and associated demographic factors

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Introduction
 >Disparities in breast cancer outcomes are prevalent among different population groups. Race/ethnicity, age, socioeconomic status, and cultural factors contribute to barriers to quality care. These barriers disrupt connection along screening, diagnosis, and treatment for breast cancer. Programs, such as patient navigators, have been proposed to reduce the barriers at multiple levels, from individual patient to providers and health systems levels, to ensure timely connection to the following steps of cancer care in underserved population.
 >We hypothesized that delay in the time interval between pathologic diagnosis and initiation of treatment in female breast cancer patients would indicate disruption in the continuity of care. We aimed to investigate whether extension of this time interval is associated with increased mortality and to identify individual demographic factors that determine delay to treatment.
 >Methods
 >Newly diagnosed stages 0 to III female breast cancer patients treated at the Johns Hopkins Hospital (JHH) from 1998 to 2005 were included in this study. Demographic and clinical information were obtained from the hospital cancer registry. A total of 2646 patients who received their first course of treatment at JHH within 6 months of diagnosis were used in our analysis. Length of time interval between pathologic diagnosis and initiation of treatment was calculated from the date of diagnosis and the date of visit for the first course of treatment provided by the cancer registry. Cox proportional hazards models were used to assess the association between survival and delayed time to initial treatment. Multiple linear regression models were used to identify individual factors associated with the time interval.
 >Results
 >After adjusting for race, age, stage, hormone receptor status, histology, and receipt of adjuvant treatment, a one-week delay in this time interval was associated with 3.7% increased risk of death after breast cancer diagnosis (hazard ratio 1.04, 95% CI 1.00 - 1.07). Black race (5.7 days longer than the White, 95% CI 3.2 - 8.2), older age at diagnosis, area of residence along with site and year of diagnosis were associated with increased time interval.
 >Conclusions
 >We suggest that the increased time interval between diagnosis and initiation of treatment indicates disconnection in the continuum of breast cancer care that is associated with unfavorable survival outcome. Shortening this time interval would be an achievable and realistic strategy to reduce disparities in cancer care, and further to improve the outcome of breast cancer at the provider and systemic level.