Doctors recommend starting treatment as soon as possible after breast cancer is diagnosed. Timely treatment reduces the risk that the cancer will spread and increases the chances for survival. Still, sometimes women delay treatment for a number of reasons, including cost and scheduling. But if treatment is delayed too long it can affect survival.
Echoing results from earlier research, two studies have found that delaying surgery by 30 days and chemotherapy by 90 days can lead to worse survival.
The studies were published online on Dec. 10, 2015 by JAMA Oncology. Read the abstracts of:
- "Delayed Initiation of Adjuvant Chemotherapy Among Patients With Breast Cancer"
- "Time to Surgery and Breast Cancer Survival in the United States"
Doctors call treatments given after surgery adjuvant treatments.
In the study looking at when women started chemotherapy, the researchers looked at the records of 24,843 women diagnosed with stage I to stage III breast cancer between 2005 and 2010 who were prescribed chemotherapy after surgery:
- 21% started chemotherapy 30 or fewer days after surgery
- 50% started chemotherapy 31 to 60 days after surgery
- 19.2% started chemotherapy 61 to 90 days after surgery
- 9.8% started chemotherapy 91 or more days after surgery
The researchers considered chemotherapy that started 91 or more days after surgery to be delayed treatment.
Compared to women who started chemotherapy within 30 days of surgery, women who started chemotherapy 91 or more days after surgery:
- were more likely to die from breast cancer -- doctors call this worse breast cancer-specific survival
- were more likely to die from any cause -- doctors call this worse overall survival
There was no difference in survival between women who started chemotherapy within 30 days of surgery and women who started chemotherapy 31 to 90 days after surgery.
Women diagnosed with triple-negative breast cancer who started chemotherapy 91 or more days after surgery were especially affected by this treatment delay: they were 53% more likely to die from breast cancer compared to women who started chemotherapy within 30 days of surgery.
Triple-negative breast cancer is estrogen-receptor-negative, progesterone-receptor-negative, and HER2-negative.
Women were more likely to delay chemotherapy if they:
- had low income
- had breast reconstruction
- had nonprivate insurance, such as Medicare
- were Hispanic
- were Black
"Given the results of our analysis, we would suggest that all breast cancer patients that are candidates for adjuvant chemotherapy should receive the treatment within 91 days of surgery or 120 days from diagnosis," said Mariana Chavez-MacGregor, M.D., of the University of Texas MD Anderson Cancer Center and her co-authors. "Administration of chemotherapy within this time frame is feasible in clinical practice under most clinical scenarios, and as medical oncologists, we should make every effort not to delay the initiation of adjuvant chemotherapy."
In the study looking at when women had surgery, the researchers looked at medical records in two databases:
- the SEER database, which is a large registry of cancer cases from sources throughout the United States maintained by the National Institutes of Health; this database also is linked to Medicare information
- the National Cancer Data Base, which contains information from more than 1,500 cancer facilities and is sponsored by the American College of Physicians and the American Cancer Society
From the SEER database, the researchers looked at the records of 94,544 people age 66 or older who were diagnosed with primary stage I to stage III breast cancer from 1992 to 2009:
- 77.7% had surgery 30 or fewer days after diagnosis
- 18.3% had surgery 31 to 60 days after diagnosis
- 2.7% had surgery 61 to 90 days after diagnosis
- 0.7% had surgery 91 to 120 days after diagnosis
- 0.5% had surgery 121 to 180 days after diagnosis
Overall, after the first 30 days after diagnosis, each 30-day delay in surgery was associated with a 9% decrease in survival. So the longer women delayed surgery, the worse survival they had. This worse survival was statistically significant for women diagnosed with stage I and stage II disease.
This means that the difference in survival was likely due to the delay in surgery and not just due to chance.
From the National Cancer Data Base, the researchers looked at the records of 115,790 people age 18 or older who were diagnosed with nonmetastatic, noninflammatory breast cancer between 2003 and 2005:
- 69.5% had surgery 30 or fewer days after diagnosis
- 24.9% had surgery 31 to 60 days after diagnosis
- 4.1% had surgery 61 to 90 days after diagnosis
- 1% had surgery 91 to 120 days after diagnosis
- 0.5% had surgery 121 to 180 days after diagnosis
Overall, after the first 30 days after diagnosis, each 30-day delay in surgery was associated with a 10% decrease in survival. This difference in survival also was statistically significant. The difference in survival was highest in women diagnosed with stage I and stage II disease.
The researchers are doing more analysis to figure out why women may decide to delay surgery.
"We…know from prior research that we have done that the number of dates the patients present for doctor visits, imaging studies, and biopsies, do affect the time to surgery," said Richard Bleicher, M.D., of the Fox Chase Cancer Center, the study’s lead author. "For instance, second or third opinions may cause increases in delay. This may be considered by some to be a very reasonable tradeoff, but it also suggests that consolidating care for office visits, imaging, and biopsies on one day, where possible, may be beneficial to limit the delay and consequences in terms of outcome.
"For elective things, such as taking time off for a family event, or where options for scheduling exist, these data provide information to patients and clinicians, so they can understand the tradeoff in survival where certain choices they make may delay surgery," he added.
If you’ve been diagnosed with breast cancer, it makes sense to take the time to do some research to make sure your diagnosis is correct and your treatment plan makes sense. But these studies strongly suggest that it also makes sense to have surgery within 30 days of diagnosis and to start chemotherapy within 90 days of surgery, especially if you’ve been diagnosed with stage I or stage II triple-negative disease.
If you’re unemployed, you may be considering delaying treatment because you’re worried about how you’ll pay for it. Don’t panic and don’t skip any doctor’s visits or delay treatment. Your life may depend on it. There are resources available to help you.
Someone at your doctor’s office may be able to give you a list of organizations that offer financial assistance for breast cancer treatments and care, as well as local organizations that offer financial assistance for your practical needs, such as transportation, food, and child care.
Also, many hospitals now include patient navigators as part of the breast cancer care team. A patient navigator can help you understand and move through the health care and insurance systems. Patient navigators also can help overcome language and cultural barriers, as well as any biases based on culture, race, or age, and can help you and your doctor communicate better. Ask your doctor or nurse for a patient navigator recommendation.
There is only one of you and you deserve the best care possible, given in a timely manner. Don’t let any obstacles get in the way of your treatment!
For more information on how you can get financial help, visit the Breastcancer.org Paying for Your Care pages.
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