Most women with breast cancer undergo primary surgery within 8 weeks of diagnosis and any later may be associated with worse overall survival, according to findings from a case series.
With no national quality metrics delineating optimal breast cancer surgery timing, the researchers recommend surgery before 8 weeks from breast cancer diagnosis.
“This time interval does not appear to have a detrimental association with cancer outcomes and allows for multidisciplinary care,” the researchers, led by Alyssa A. Wiener, MD, from University of Wisconsin School of Medicine and Public Health, Madison, said.
But, in an accompanying editorial, two surgical oncologists questioned whether faster surgery is always better.
“Efficiency might associate with quality, but doesn’t always ensure it,” Rita Mukhtar, MD, and Laura Esserman, MD, with the Division of Surgical Oncology, University of California San Francisco said.
The study and editorial were published online March 1 in JAMA Surgery.
Optimal Timing for Surgery?
Some studies have found worse survival outcomes for women who experience delays between breast cancer diagnosis and surgical treatment, but the optimal window for surgery and the point at which surgery becomes less advantageous remain unknown.
Using the National Cancer Database, Wiener and colleagues identified 373,334 women (median age, 61) who were diagnosed with stage I to stage III ductal or lobular breast cancer from 2010 to 2014 and followed up through 2019.
All women underwent surgery as their first course of treatment. Patients with prior breast cancer, those who had neoadjuvant or experimental therapy, missing receptor information, or were diagnosed with breast cancer on the date of their primary surgery were excluded.
Most patients had timely surgery. The median time to surgery was 30 days, and 88% of patients underwent surgery before the 57-day time point.
Only 12% of patients had surgery more than 8 weeks after their diagnosis. Factors associated with longer times to surgery included age younger than 45, having Medicaid or no insurance, and lower household income.
The overall 5-year survival for the cohort was high at 90%. On multivariable analysis, the researchers found no statistically significant association between time to surgery and overall survival when surgery was performed between 0 and 8 weeks.
However, women who had surgery 9 or more weeks after diagnosis had a significantly higher rate of death within 5 years compared with surgery performed between 0 to 4 weeks (hazard ratio [HR], 1.15; P < .001). Performing surgery up to 9 weeks (57-63 days) post-diagnosis also did not appear to be negatively associated with survival.
This study “highlights that time to treatment of breast cancer is important,” said Sarah P. Cate, MD, director, Breast Surgery Quality Program, Mount Sinai Health System, New York, who wasn’t involved in the study. “Surgery is only one-third of the treatment of breast cancer so these patients who had longer delays to the OR may have also not started their post-surgery treatments in time.”
In addition, the study found that socioeconomic status — Medicaid or uninsured status and lower household incomes — was associated with longer times to surgery.
“Socioeconomic factors like these may be independently associated with worse outcomes and may contribute to some of the disparities in cancer outcomes observed for resource-limited patients due to delayed care,” the authors said.
Identifying 8 weeks as a goal for time to surgery can help uncover delays associated with socioeconomic factors and provide adequate time for decision-making, the researchers noted.
Is Faster Always Better?
Wiener and colleagues cautioned, however, that their findings should be considered “hypothesis generating,” given that decision-making surrounding breast cancer surgery is complex.
Importantly, the authors noted, tumor characteristics, such as tumor size, nodal status, and receptor subtype, appeared to have a pronounced impact on overall survival compared with timing of surgery. For instance, compared with a tumor size of 2 cm or fewer, larger tumors — those > 2 cm to ≤ 5 cm and > 5 cm — were associated with worse survival (HR, 1.80 and 2.62, respectively).
“This highlights that tumor biology is the primary driver of patients’ breast cancer outcomes,” the authors noted.
In an accompanying editorial, two surgical oncologists highlighted that faster may not always be better.
For instance, Mukhtar and Esserman explained, if a patient with a large node-positive, triple-negative breast cancer receives surgery within a week of diagnosis, “one must question whether this timely care represents quality care, as the opportunity to understand tumor response and affect breast cancer survival has been lost.”
The editorialists noted that time to surgery might also matter very little for indolent, screen-detected cancers, and time to treatment start might matter a lot for fast-growing, interval cancers.
In addition, they questioned whether including the socioeconomic factors highlighted in the overall model would “mitigate the association between time to surgery and survival seen in this study.”
Overall, “operating too soon could indicate lack of quality, while operating too late perhaps reflects lack of access to care,” the editorialists said.
This study was supported by grants from the National Cancer Institute and the National Institutes of Health. Wiener and Cate report no relevant financial relationships. Esserman is a member of the Blue Cross Medical advisory panel, a board member of the Quantum Leap Healthcare Collaborative, and leads an investigator-initiated vaccine trial for high-risk ductal carcinoma in situ, which is funded by Merck.
JAMA Surgery. Published online March 1, 2023. Abstract. Editorial.
For more news, follow Medscape on Facebook, Twitter, Instagram, and YouTube.
Source: Read Full Article