Whether your treatment complies with recommended guidelines depends on systems that don’t appear to deliver equally to all.
Risk of death was 43% higher for women with early-stage breast cancer whose treatment did not comply with the timeframes set out in the 2020 Cancer Australia guidelines, according to Queensland research published in the MJA this week.
“Breast cancer specific survival was poorer for women for whom the diagnosis to surgery, surgery to chemotherapy, or chemotherapy to radiotherapy intervals exceeded guideline recommended limits. Our findings support 2020 Australian guideline recommendations regarding timely care,” the authors wrote.
The study involved just over 3000 women aged 20-70, diagnosed with invasive breast cancer from March 2010 to June 2013, followed up to the end of 2020.
Records and interviews were used to determine if their care complied with the Cancer Australia guidelines, which were based on expert consensus. The guidelines recommend timeframes for six therapy intervals: diagnosis to neoadjuvant therapy (two to four weeks), neoadjuvant therapy to surgery (four to six weeks), diagnosis to surgery (within a month), surgery to chemotherapy (within four to six weeks), surgery to radiotherapy (within eight weeks) and chemotherapy to radiotherapy (within three to four weeks).
In the study group, treatment was not compliant with recommended timeframes for 45% of the women. Non-compliance was highest in the surgery to radiotherapy interval (49% of patients) and lowest for time from diagnosis to surgery (4.5%).
During follow-up, 165 women (5.4%) died of breast cancer.
While the 10-year survival rate was only just under 2% lower overall for women whose treatment was non-compliant, that differed depending on which specific timeframes were not adhered to.
Those whose surgery occurred more than 29 days from diagnosis had a 76% higher chance of death than those whose treatment complied with guidelines. That climbed to 114% higher if it was longer than 45 days, and a 4.4% lower survival rate at 10 years.
Chance of death was 63% higher when the surgery to chemotherapy interval was greater than 36 days. It was 62% higher when there were more than 28 days between chemotherapy and radiotherapy, with a 3.8% lower survival rate at 10 years. More than 31 days and the chance went up to 83% higher than those who’d received treatment in the recommended timeframe.
“Survival outcomes were not significantly influenced by compliance with recommendations for the other four intervals,” the authors said.
The study also looked at the socio?demographic factors of family history, smoking, marital status, annual income, private insurance status, and residential remoteness, all of which affected whether a person received care within recommended timeframes.
Compared to people who were diagnosed through a private screening facility, the chances of having non-compliant timeframe intervals were 58% higher for those whose cancer was diagnosed through a public screening facility and 39% higher for those diagnosed because they had symptoms. The lack of full private health insurance conferred a 96% higher chance of non-compliance than having full cover. And living outside a major city increased the chance of delayed treatment by 38%.
Smokers had a 40% higher rate of non-compliant treatment than never-smokers. And those who earned $52,000 a year or less had a 30% higher rate than people who made $130,000 or more.
Time of year at start or completion of treatment also had an effect, with December and January patients having twice the chance of treatment delays than those seen the rest of the year.
“Health system practices and hospital burden, as well as factors such as geographic and cultural diversity, probably influence the timeliness of breast cancer care. Opportunities for shortening the diagnosis?to?treatment window while maintaining quality of care may be facilitated by digital health care innovations integrated with person?centred care and a survivorship approach,” the authors wrote.
While the data is quite old, it’s not possible to know definitely whether the findings are still representative of modern practice because efficiency of cancer care is not routinely measured, said surgical oncologist Professor Christobel Saunders. (In this study, complete data was only available for 56% of eligible patients.)
“It’s great that this group has highlighted the issue,” she told OR.
Professor Saunders, who was not involved in this study, co-chaired the expert group for the Cancer Australia guidelines. And as chair of All.Can, an international organisation focused on efficient use of cancer resources which last year released its Cancer Efficiency Metrics Study, is advocating for better recording of efficiency measures.
“I am glad to see the guidelines recommendations are borne out by evidence, albeit sad to see these long wait times for those most under-privileged which again highlights the inequalities in our system, which the upcoming Cancer Australia plan seeks to eradicate,” Professor Saunders said,
“Of course, this work cannot tell us the cause of the worse survival in those with longer wait times to treatment, but gives a strong signal we need to get better data and then act on it.?Navigation is one way forward (All.Can are doing work in this area) but really more efficient health systems is the key.”