Prakash Ipshita, Thomas Samantha M, Greenup Rachel A, Plichta Jennifer K, Rosenberger Laura H, Hyslop Terry, Fayanju Oluwadamilola M
Department of Surgery, Duke University Medical Center, Box 3513, Durham, NC, 27710, USA.
Department of Surgery, Glen Campus, Royal Victoria Hospital, McGill University Health Centre, 1001 Blvd Decarie, Montreal, QC, Canada.
Breast Cancer Res Treat. 2021 Apr;186(2):535-550. doi: 10.1007/s10549-020-06012-7. Epub 2020 Nov 18.
Time to surgery (TTS) is a potentially modifiable factor associated with survival after breast cancer diagnosis and can serve as a proxy for quality of oncologic care coordination. We sought to determine whether factors associated with delays in TTS vary between patients who receive neoadjuvant systemic therapy (NST) vs upfront surgery and whether the impact of these delays on overall survival (OS) varies with treatment sequence.
Women ≥ 18 years old with Stage I-III breast cancer were identified in the National Cancer Database (2004-2014). Multivariate linear regression stratified by treatment sequence (upfront surgery vs NST [neoadjuvant chemotherapy {NAC}, neoadjuvant endocrine therapy {NAE}, or both {NACE}]) was used to identify factors associated with TTS. Cox proportional hazards models were used to estimate the effect of TTS on overall survival (OS).
Of 693,469 patients, 14.8% (n = 102,326) received NST (NAC n = 85,143, NAE n = 10,004, NACE n = 7179). Non-White race/ethnicity, no or government-issued insurance, more extensive surgery (i.e., mastectomy and contralateral prophylactic mastectomy vs breast-conserving surgery), and post-mastectomy reconstruction were associated with significantly longer adjusted TTS for NAC and upfront-surgery recipients, but only upfront-surgery patients had progressively worse OS with increasing TTS (> 180 vs ≤ 30 days: HR = 1.31, all p < 0.001).
Surgery extent, race/ethnicity, and insurance were associated with TTS across treatment groups, but longer TTS was only associated with worse OS in upfront-surgery patients. Our findings can help inform surgeon-patient communication, shared decision making, care coordination, and patients' expectations throughout both NST and in the perioperative period.
手术时间（TTS）是与乳腺癌诊断后生存相关的一个潜在可改变因素，可作为肿瘤护理协调质量的一个指标。我们试图确定接受新辅助全身治疗（NST）与直接手术的患者之间，与TTS延迟相关的因素是否存在差异，以及这些延迟对总生存期（OS）的影响是否随治疗顺序而变化。
在国家癌症数据库（2004 - 2014年）中识别年龄≥18岁的I - III期乳腺癌女性患者。采用按治疗顺序分层的多变量线性回归（直接手术与NST[新辅助化疗{NAC}、新辅助内分泌治疗{NAE}或两者{NACE}]）来确定与TTS相关的因素。采用Cox比例风险模型来估计TTS对总生存期（OS）的影响。
在693,469例患者中，14.8%（n = 102,326）接受了NST（NAC n = 85,143，NAE n = 10,004，NACE n = 7179）。非白人种族/族裔、无保险或政府发放的保险、更广泛的手术（即乳房切除术和对侧预防性乳房切除术与保乳手术相比）以及乳房切除术后重建与NAC和直接手术患者调整后的TTS显著延长相关，但只有直接手术患者的OS随着TTS增加而逐渐变差（>180天与≤30天：HR = 1.31，所有p < 0.001）。
手术范围、种族/族裔和保险与各治疗组的TTS相关，但仅直接手术患者中较长的TTS与较差的OS相关。我们的研究结果有助于在整个NST期间和围手术期为外科医生与患者的沟通、共同决策、护理协调以及患者期望提供信息。
