Rayson Daniel, Chiasson Darrell, Dewar Ron
Division of Medical Oncology, Queen Elizabeth II Health Sciences Centre, Halifax, NS.
CMAJ. 2004 Mar 16;170(6):957-61. doi: 10.1503/cmaj.1020972.
A number of studies have examined time intervals between care steps in breast cancer diagnosis and treatment. The objective of this study was to document the elapsed time from first clinical or mammographic detection of breast abnormality to initiation of first adjuvant therapy in women with invasive breast cancer in Nova Scotia and to examine the effect of age, disease stage and place of residence on these intervals.
All dates were abstracted from patient charts and the Oncology Patient Information System. Eligible women were those with invasive breast cancer detected by Sept. 1, 1999, who were referred to 1 of 2 provincial cancer treatment centres by Sept. 1, 2000. All time intervals were calculated in days, and only patients experiencing both care events defining an interval were included in the analysis of time to event for that interval. We used proportional hazards regression analysis to evaluate the influence of patient age, disease stage and place of residence on times between care events.
A total of 776 new diagnoses of breast cancer were reported to the Nova Scotia Cancer Registry over the study period. Of the 776, 467 met the inclusion criteria, and 364 patients were eligible for analysis. The overall median time from clinical or mammographic detection of breast cancer to initiation of first adjuvant therapy was 91 days (interquartile range 72-123 days). Disease stage was the strongest predictor of elapsed time: the median interval from disease detection to initiation of first adjuvant therapy for patients with stage I disease was 118 days, as compared with 85 days for those with stage II disease and 75 days for those with stage III disease (adjusted hazard ratio [HR] 2.1, 95% confidence interval [CI] 1.6-2.8). Patients aged 70 years or more at diagnosis experienced longer elapsed times (median interval 98 days) than did younger patients (93 days for those aged 50-69 years and 82 days for those aged 49 years or less) (adjusted HR 1.6, 95% CI 1.1-2.4).
Women aged 70 or more and those with stage I breast cancer experienced longer elapsed times from disease detection to initiation of first adjuvant therapy than did younger women and those with more advanced disease. These findings may have implications for the design of interventions to minimize intervals between steps in breast cancer care and should be validated within the Canadian context. Future investigation exploring the full spectrum of breast cancer care may lead to a more complete understanding of processes and gaps in the current system.
多项研究探讨了乳腺癌诊断和治疗过程中各护理步骤之间的时间间隔。本研究的目的是记录新斯科舍省浸润性乳腺癌女性从首次临床或乳腺钼靶检查发现乳房异常到开始首次辅助治疗的时间，并研究年龄、疾病分期和居住地对这些时间间隔的影响。
所有日期均从患者病历和肿瘤患者信息系统中提取。符合条件的女性为1999年9月1日前被诊断为浸润性乳腺癌，且在2000年9月1日前被转诊至省级两个癌症治疗中心之一的患者。所有时间间隔均以天数计算，只有经历了定义某个间隔的两个护理事件的患者才被纳入该间隔事件发生时间的分析。我们使用比例风险回归分析来评估患者年龄、疾病分期和居住地对护理事件间隔时间的影响。
在研究期间，新斯科舍省癌症登记处共报告了776例新诊断的乳腺癌病例。其中，467例符合纳入标准，364例患者符合分析条件。从临床或乳腺钼靶检查发现乳腺癌到开始首次辅助治疗的总体中位时间为91天（四分位间距72 - 123天）。疾病分期是间隔时间的最强预测因素：I期疾病患者从疾病发现到开始首次辅助治疗的中位间隔时间为118天，II期疾病患者为85天，III期疾病患者为75天（调整后风险比[HR] 2.1，95%置信区间[CI] 1.6 - 2.8）。诊断时年龄在70岁及以上的患者间隔时间较长（中位间隔98天），而年轻患者间隔时间较短（50 - 69岁患者为93天，49岁及以下患者为82天）（调整后HR 1.6，95% CI 1.1 - 2.4）。
70岁及以上的女性和I期乳腺癌患者从疾病发现到开始首次辅助治疗的间隔时间比年轻女性和疾病分期更晚的患者更长。这些发现可能对设计旨在尽量缩短乳腺癌护理各步骤之间间隔时间的干预措施具有启示意义，并且应在加拿大背景下进行验证。未来对乳腺癌护理全流程的研究可能会使我们对当前系统中的流程和差距有更全面的了解。
