Fast track — ArticlesEffect on survival of delays in referral of patients with breast-cancer symptoms: a retrospective analysis
Introduction
The effect of delay in diagnosis on survival from breast cancer is controversial. Results from the National Health Service breast-screening programme in the UK, taken in conjunction with longer-term studies of breast screening, support the contention that detection of cancers at an earlier stage, or smaller size, will influence prognosis. Some cancers remain localised to the breast (and are therefore curable by surgery alone). The paradigm that every breast cancer represents a systemic disease from its onset with micrometastatic spread being the norm is disputed, and detection of small lesions remains a worthwhile objective.
Most reports support the concept that delay adversely affects prognosis. A systematic overview of published studies suggested that delays from symptom onset to ultimate treatment are important.1 The various components of delay include delay by patients (the time from first noticed symptoms to the seeking of medical help), referral delay (first consultation with primary-care physician to hospital referral), and hospital delay (from referral to the start of definitive treatment, generally because of inefficiency or missed diagnosis). Hospital delay is of interest to the legal profession and claims for delay in diagnosis of breast cancer are common, rising in number, and increasingly expensive in the UK and, especially, in the USA.2
The UK government has made improvements in the delivery of breast-cancer services a priority and has given an extra £10 million to improve services. The government also gave priority to measures to shorten delays to first hospital appointments; they aim to shorten delays to no more than 2 weeks for a somewhat illdefined subgroup of women with suspected breast cancer. The policy says nothing about delays for women not labelled in this way who may subsequently be diagnosed as having breast cancer. To keep to a minimum the time a patient with symptoms has to wait for a diagnosis is admirable, and common sense dictates that once a cancer has been detected, the patient should be admitted quickly for surgery or other primary treatment (ideally within 7–21 days). Very short times may be unhelpful, however, because the patient may not have had enough time to come to terms with the diagnosis. Time is also needed to seek further information and discuss the implications of different treatment options.
We therefore investigated the effect of delay by providers on survival. Our hypothesis was that the delays typically seen in routine clinical practice would not be associated with lower survival rates.
Section snippets
Patients and methods
We used data from the Yorkshire Cancer Registry (now part of Northern and Yorkshire Cancer Registry and Information Service) to investigate the relation between referral for treatment and the effect of delay on survival.
Results
Symptom date was the least well recorded of all data (9142 [25%] patients); family-physician referral, hospital, and treatment dates were available for 18 521 (51%) of patients, and hospital and treatment dates available in 29 137 (80%, table 1). Survival did not differ significantly between patients who underwent surgery who had all dates, partial dates, and missing dates (data not shown). Data collection for these items improved gradually over time, with increases in complete data on
Discussion
The management of patients with breast cancer has improved in the UK. The impact of the Calman-Hine document on provision of cancer services,3 along with the Department of Health Clinical Outcome Group advice to commissioners4 has allowed evidence-based decisions on best management to be publicised. The profession itself addressed these issues in the aftermath of the successful implementation of a national screening programme for breast cancer through publications of the British Breast Group5
References (8)
- et al.
The influence of delay in patients with breast cancer: a systematic review
Lancet
(1999) - Physician Insurers Association of America. Breast cancer study....
Policy framework for commissioning cancer services: a report to the Expert Advisory Group on Cancer to the Chief Medical Officers of England and Wales
(1995)Improving outcomes in breast cancer
(1996)
Cited by (166)
Association Between Time to Operation and Pathologic Stage in Ductal Carcinoma in Situ and Early-Stage Hormone Receptor-Positive Breast Cancer
2020, Journal of the American College of SurgeonsDelay in breast cancer diagnosis: a Brazilian cohort study
2019, Public HealthCitation Excerpt :The eligible patients were interviewed at the first consultation at oncological reference hospital. The variables described below were selected based on the results found in previous studies.6–15 Variables related to the health service were adapted and classified by authors, according to the specificities of the Brazilian Health System.