The influence of hospital volume and surgical treatment delay on long-term survival after cancer surgery

BackgroundWe conducted a population-based retrospective cohort study to investigate the influence of hospital volume, delay of surgery, and both together on the long-term survival of postoperative cancer patients.MethodsUsing information from the Korea Central Cancer Registry from 2001 through 2005 and the National Health Insurance claim database, we determined survival for 147 682 patients who underwent definitive surgery for any of six cancers.ResultsRegardless of cancer site, surgical patients in low- to medium-volume hospitals showed significantly worse survival [adjusted hazard ratio (aHR) = 1.36–1.86] than those in high-volume hospitals in multivariable analyses. Among the latter, treatment delays > 1 month were not associated with worse survival for stomach, colon, pancreatic, or lung cancer but were for rectal [aHR = 1.28; 95% confidence interval (CI), 1.17–1.40] and breast (aHR = 1.59; 95% CI, 1.37–1.84) cancer. For patients in low- to medium-volume hospitals, treatment delay was associated with worse survival for all types of cancer (aHR = 1.78–3.81).ConclusionOur findings suggest that the effect of hospital volume and surgical treatment delay on overall survival of cancer patients should be considered in formulating or revising national health policy.     

Response to treatment and its influence on survival in metastatic breast cancer

The clinical response to first systemic therapy of 381 patients with metastatic breast cancer was assessed; the influence of the category of this first response on eventual survival from diagnosis of first distant metastasis was analyzed. Survival from diagnosis of first distant metastasis was found to be similar whether the patient had a complete response, a partial response, or stable disease; only when progressive disease occurred with first systemic treatment was survival significantly shortened. This similarity in survival whatever the category of response from diagnosis of first distant metastases was found whether the patient received chemotherapy or hormone therapy as first systemic treatment, and whether the patient was premenopausal or postmenopausal; there was some suggestion on analysis of premenopausal patients treated with hormone therapy as first systemic therapy that a complete response conferred a survival advantage, but the numbers were small in this group. When complete responders to first systemic therapy as well as any other subsequent systemic therapy were analyzed for survival from diagnosis of first distant metastasis, again, no survival advantage could be found compared to the other response categories, but the complete response rate was low owing to the unselected nature of this group of study patients. It is concluded that the categories of complete, partial, or stable response to therapy have no great significance in terms of survival; the category of progressive disease to first systemic therapy is, however, associated with a shorter survival in all the analyses performed. We suggest that assessment of a treatment's worth should be based as much on the patient's subjective feeling of well-being as on the magnitude of the tumor response, since with currently available therapies, provided some form of response is obtained, the magnitude of the response does not appear to translate into any major survival advantage. This study points up the disparity between research-oriented criteria of response (survival, response rate, and its magnitude) and patient care criteria of response (survival and quality of life).     

Risk factors for delay in symptomatic presentation: a survey of cancer patients

Background:

Delay in symptomatic presentation leading to advanced stage at diagnosis may contribute to poor cancer survival. To inform public health approaches to promoting early symptomatic presentation, we aimed to identify risk factors for delay in presentation across several cancers.

Methods:

We surveyed 2371 patients with 15 cancers about nature and duration of symptoms using a postal questionnaire. We calculated relative risks for delay in presentation (time from symptom onset to first presentation >3 months) by cancer, symptoms leading to diagnosis and reasons for putting off going to the doctor, controlling for age, sex and deprivation group.

Results:

Among 1999 cancer patients reporting symptoms, 21% delayed presentation for >3 months. Delay was associated with greater socioeconomic deprivation but not age or sex. Patients with prostate (44%) and rectal cancer (37%) were most likely to delay and patients with breast cancer least likely to delay (8%). Urinary difficulties, change of bowel habit, systemic symptoms (fatigue, weight loss and loss of appetite) and skin symptoms were all common and associated with delay. Overall, patients with bleeding symptoms were no more likely to delay presentation than patients who did not have bleeding symptoms. However, within the group of patients with bleeding symptoms, there were significant differences in risk of delay by source of bleeding: 35% of patients with rectal bleeding delayed presentation, but only 9% of patients with urinary bleeding. A lump was a common symptom but not associated with delay in presentation. Twenty-eight percent had not recognised their symptoms as serious and this was associated with a doubling in risk of delay. Embarrassment, worry about what the doctor might find, being too busy to go to the doctor and worry about wasting the doctor''s time were also strong risk factors for delay, but were much less commonly reported (<6%).

Interpretation:

Approaches to promote early presentation should aim to increase awareness of the significance of cancer symptoms and should be designed to work for people of the lowest socioeconomic status. In particular, awareness that rectal bleeding is a possible symptom of cancer should be raised.     

延迟辅助化疗对乳腺癌患者生存期的影响(英文)

Objective: The proper time to commence adjuvant chemotherapy after primary surgery for breast cancer is unknown. It is usually prescribed within 2-3 months after definitive surgery. The aim of this retrospective study was to assess the impact of adjuvant chemotherapy (CT) delay beyond 3 weeks ( 21 days) in premenopausal patients with ER-absent tumors being treated for early stages breast cancer on overall survival (OS) and disease-free survival (DFS). Methods: This retrospective study was conducted through revision of medical records of premenopausal patients diagnosed with early stage Ⅰ-ⅢA breast cancer and ER-absent tumors who received adjuvant CT after definitive surgery at the Department of Clinical Oncology, Ain-Shams University Hospitals. Results: Between 2005 and 2008, 105 patients were retrospectively analyzed and included. Patients were divided into 2 groups: Group A including 48 patients who started adjuvant CT<21 days of surgery and group B which included 57 patients who had CT delay ≥ 21 days. Both groups were matched demographically. Comparisons of overall survival, and disease-free survival between group A and group B patients all favored group A. At 5-year the OS rates were 87% and 73% for groups A and B respectively (P=0.001), while DFS rates were 85% and 64% in groups A and B respectively (P=0.001). Analysis of other prognostic factors (age, T, N, grade, HER2 status, surgery type, CT type, local radiotherapy received) were analyzed. Only nodal status predicted for worse DFS (P=0.05) and OS (P=0.006). Conclusion: Delay in initiating adjuvant chemotherapy for early stage breast cancer patients with ER-absent tumors was associated with a decrease in both OS and DFS rates.     

Effects of young age at presentation on survival in breast cancer

Background  

Young age remains a controversial issue as a prognostic factor in breast cancer. Debate includes patients from different parts of the world. Almost 50% of patients with breast cancer seen at the American University of Beirut Medical Center (AUBMC) are below age 50.     

Time from first presentation in primary care to treatment of symptomatic colorectal cancer: effect on disease stage and survival

Background:

British 5-year survival from colorectal cancer (CRC) is below the European average, but the reasons are unclear. This study explored if longer provider delays (time from presentation to treatment) were associated with more advanced stage disease at diagnosis and poorer survival.

Methods:

Data on 958 people with CRC were linked with the Scottish Cancer Registry, the Scottish Death Registry and the acute hospital discharge (SMR01) dataset. Time from first presentation in primary care to first treatment, disease stage at diagnosis and survival time from date of first presentation in primary care were determined. Logistic regression and Cox survival analyses, both with a restricted cubic spline, were used to model stage and survival, respectively, following sequential adjustment of patient and tumour factors.

Results:

On univariate analysis, those with <4 weeks from first presentation in primary care to treatment had more advanced disease at diagnosis and the poorest prognosis. Treatment delays between 4 and 34 weeks were associated with earlier stage (with the lowest odds ratio occurring at 20 weeks) and better survival (with the lowest hazard ratio occurring at 16 weeks). Provider delays beyond 34 weeks were associated with more advanced disease at diagnosis, but not increased mortality. Following adjustment for patient, tumour factors, emergency admissions and symptoms and signs, no significant relationship between provider delay and stage at diagnosis or survival from CRC was found.

Conclusions:

Although allowing for a nonlinear relationship and important confounders, moderately long provider delays did not impact adversely on cancer outcomes. Delays are undesirable because they cause anxiety; this may be fuelled by government targets and health campaigns stressing the importance of very prompt cancer diagnosis. Our findings should reassure patients. They suggest that a health service''s primary emphasis should be on quality and outcomes rather than on time to treatment.     

Does delay in diagnosis of breast cancer affect survival?

Summary 1675 breast cancer patients in the Auckland regional area have been divided into two major groups according to delay in diagnosis greater or less than six weeks. Overall there is no difference in survival although the variables tumour size, skin attachment, and nipple retraction are more common in the group with longer delay, and grade III tumours in those with short delay. Three important prognostic variables (the presence of tumour steroid receptors, positive axillary nodes, and distant metastases at diagnosis) are equally distributed and have a similar effect on survival within the two delay groups. However, in a subgroup of women with negative axillary nodes, short delay is associated with poorer survival, independent of tumour size. More tumours with grade III histology and a negative progesterone receptor status are found in this subgroup. Thus, short delay may constitute a new prognostic variable of some importance when in association with negative axillary nodes.     

Relation between delay and survival in 596 patients with breast cancer

To evaluate the influence of delay between first symptom and first treatment upon survival the medical records of 596 patients with breast cancer were reviewed. The following intervals were considered: less than 3 months; 3-6 months and greater than 6 months. Patients in the less than 3 months delay group had a better distribution by clinical stages and a 10-year survival rate higher than those in the longer delay groups (p = 0.034). However, within each stage no statistically significant difference in survival according to delay was observed. A Cox multivariate analysis revealed that performance status and stage of disease were independent predictors of survival, but not delay. Assuming the best prognosis for patients with clinical stages I and II and less than 3 months delay, the group with longer delay times had 15 deaths over what would have been predicted. This adverse effect was observed almost exclusively among patients over age 50 (14/15).     

The effects of patient delay and symptoms other than a lump on survival in breast cancer

This study examined the relationship of survival in breast cancer to delay in treatment and the presence of symptoms. Data were analyzed for 664 patients diagnosed from 1975-1979 at 15 hospitals in Brooklyn, New York. Pathologic risk factors were defined to classify breast cancer into less (Class I) or more aggressive (Class III) disease. Delay and survival were not significantly associated among women diagnosed with Class I disease. Delay was associated with poor survival for patients with Class III disease (P less than 0.001). The presence of symptoms other than a lump was associated with longer delay and poorer survival in patients with Class II and III disease. These findings suggest that the contradictory relationship between delay and survival reported by others may be due to variations in the proportions of slow and fast growing tumors and that fast growing tumors must be treated promptly for a successful result.     

Diagnostic delay in symptomatic colorectal cancer

Previous research on colorectal cancer patients has suggested that considerable delay can occur once the patient has sought medical care. However, little information has been available on the possible components of this delay. In this study, detailed information on diagnostic delays was collected from 294 symptomatic patients. Of these patients, 46% reported experiencing at least one delay. Three types of diagnostic delay were identified and were associated with different lengths of delay. Of all the delays, 31% were due to difficulties in scheduling initial or subsequent office visits or laboratory tests; these were associated with an average delay of 3 weeks. Physician-related delays (e.g., misdiagnosis or observation of symptoms without specific action) comprised 46% of all diagnostic delays and resulted in an average delay of 18 weeks. The remainder of the delays were patient-related and resulted in an average delay of 12 weeks. There was no association between any of these three delay types, suggesting that attempts to reduce diagnostic delay should encompass all three types in order to be maximally effective.     

Variations in treatment and survival in breast cancer

To achieve optimum quality of care for women with breast cancer in the UK, uniformity of care in accordance with consensus guidelines is needed. This review highlights variations in provision of care for women with breast cancer, with particular emphasis on care received in the UK, examines differences in survival, and discusses the factors that may underlie these differences. Strong variation in treatment was identified, which appeared to affect survival significantly. These findings reinforce the need for women with breast cancer to be treated by dedicated specialists working within a multidisciplinary team to provide a high standard of care.     

The influence of the anaesthetic on survival rates of breast cancer patients after surgery

The end results of therapy of 1,358 breast cancer patients were studied. Anaesthesia was performed by ether-nitrogen-oxygen (554 cases) or halothane-nitrogen-oxygen (804 cases) mixture with addition of oxygen. The method of Holstead was employed in all cases. A comparison of groups of patients on the basis of such parameters as the anaesthetic used, age and degree of tumour progression (according to the TNM classification and results of postoperative histological assays) showed them to be identical. The study showed that the type of anaesthesia influenced the end results of therapy of cancer patients: the survival rates of patients receiving halothane anaesthesia were much higher than those of the ether-anaesthetized patients. The differences were most pronounced among patients who received pre-operative radiation therapy and post-operative chemotherapy as well as in cases of metastasis spread into regional lymph nodes. The mechanism of the effect of the anaesthetic on the survival rates of cancer patients may be explained on the basis of the data available on the varying influences of anaesthetics on the pituitary-adrenal cortex system and carcinemia development during operation as well as the role of immunity in tumour cell implantation and growth of metastases.     

The effect of delays in treatment for breast cancer metastasis on survival

It is generally accepted that delay in receiving treatment for breast cancer results in adverse outcomes. The purpose of this study was to evaluate the impact of delay in treatment after the diagnosis of metastatic disease on survival measured from metastatic breast cancer diagnosis and from first treatment while controlling for immortal time effect among patients with metastatic breast cancer. A total of 553 patients with breast cancer metastasis diagnosis from one large urban practice have been followed between January 1, 1999 and June 30, 2008. Prognostic factors and outcomes of these patients were analyzed using log-rank test and Cox regression model. Backward stepwise selection of covariates was conducted to assess the association of treatment delay with survival. The median survival was 40 months (range 1–114 months), with 265 (47.9%) women alive and 288 (52.1%) having died at the end of the follow-up period. Treatment delays of more than 12 weeks had impact on poor survival from first treatment than the delays of 4–12 weeks with borderline significance level (HR 1.76, 95% CI 0.99–3.13, P = 0.056) in multivariate analysis, adjusted by BMI, history of hypertension, ER/PR status, HER2 status, number of metastatic sites, and liver metastasis. Moreover, the interval of 12–24 weeks, compared to the interval of 4–12 weeks was associated with greater risk of death from first treatment (HR 2.39, 95% CI 1.19–4.77, P = 0.014). The treatment delay interval of >12 weeks was not related with survival since metastatic breast cancer diagnosis, compared to the 4–12 weeks of treatment delays. This study demonstrated that delays of over 12 weeks in receiving treatment for metastatic breast cancer were related to adverse survival outcomes measured from initiation of first treatment. The findings of this study support targeted efforts to ensure prompt treatment initiation in patients diagnosed with metastatic breast cancer.     

The influence of menstrual risk factors on tumor characteristics and survival in postmenopausal breast cancer

Introduction  

Hormonal factors are implicated in tumor progression and it is possible that factors influencing breast cancer induction could affect prognosis. Our study investigated the effects of menstrual risk factors on tumor characteristics and survival in postmenopausal breast cancer.     

Differences in subtype distribution between screen-detected and symptomatic invasive breast cancer and their impact on survival

Purpose

Stage shift is considered a major reason for more favorable outcomes in patients with screen-detected breast cancer. However, even after adjusting for clinical stage, unresolved issues concerning the reasons for a survival benefit associated with screening programs remain. This study aims to evaluate differences in subtype distribution and outcomes among patients with screen-detected and symptomatic invasive breast cancer and assess whether variations in subtype distribution could explain differences in prognosis.

Methods

Survival analysis was performed to estimate the likelihood of distant recurrence and death in 1132 patients. Subtypes were defined as luminal A [estrogen receptor (ER)+ and/or progesterone receptor (PR)+, human epidermal growth factor receptor 2 (HER2)?, and Ki67 low], luminal B (HER2?) (ER+ and/or PR+, HER2?, and Ki67 high), luminal B (HER2+) (ER+ and/or PR+ and HER2+), HER2 overexpressing (ER?, PR?, and HER2+), and triple negative (ER?, PR?, and HER2?).

Results

Screen-detected cancers had favorable clinicopathological characteristics, such as smaller tumor size and a lower frequency of lymph node involvement. Women with screen-detected cancers had a survival advantage. Subtype distribution differed significantly among women with screen-detected and symptomatic cancer. Screen-detected cancers were more likely to be luminal A and less likely to be HER2 overexpressing or triple negative cancer compared with symptomatic cancers (luminal A 61.3 vs. 44.2%, HER2 overexpressing 4.0 vs. 8.0%, triple negative 8.0 vs. 15.9%). Node status, mode of detection, and subtype were independent prognostic factors in the multivariate analysis.

Conclusions

Differences in subtype distribution between screen-detected and symptomatic cancer could partially explain differences in outcomes.

     

The effect of age on treatment choice and survival in elderly breast cancer patients

To investigate the effect of age on treatment choice and survival in patients with breast cancer, data from the cancer registry of the Netherlands Cancer Institute (NKI, Amsterdam, The Netherlands) on 611 women have been analyzed. All patients 55 years and older admitted to the NKI for primary treatment of breast cancer between 1981 and 1986 were selected. For women 75 years and older, physicians were less likely to use treatment of adjuvant radiation therapy after a mastectomy and more often employed primary hormonal therapy only for local stage disease than for younger patients. Life-table analysis showed that disease-specific survival at 7 years for patients 65 through 74 years of age was significantly better (65%) than that of the youngest (55%) and the oldest age group (50%). In multivariate regression analysis (Cox), age older than 74 years was significantly and independently associated with a shorter disease-specific survival as compared with patients younger than 75 years. This difference in survival, however, does not seem to be the result of the difference in treatment between the age groups, but suggests an influence of age-related factors such as comorbid diseases and weak physical condition, which manifest themselves most strongly in the oldest age category and make the older woman more vulnerable to the course of malignant disease.     

The influence of tamoxifen treatment on the oestrogen receptor in metachronous contralateral breast cancer

Adjuvant tamoxifen treatment reduces the occurrence of contralateral breast cancer (CBC). The aim of the study was to investigate the hypothesis that adjuvant tamoxifen reduces the occurrence of oestrogen-receptor (ER)-positive CBC, but not the growth of ER-negative CBCs, and to examine survival after diagnosis of CBC. For the study, ER status was immunohistochemically assessed in CBCs of 35 tamoxifen-treated patients and 115 patients without previous hormonal treatment. Cases were retrieved from a series of patients treated from 1984 to 1995 at nine hospitals. The interval between ipsi- and contralateral breast cancer was at least 1 year. It was seen that the proportion of patients with an ER-negative CBC was significantly higher among those with prior tamoxifen treatment: 37% vs 18% (P=0.047). No difference between the two groups in overall and disease-specific survival following CBC was found. However, the stage differed for both groups: tamoxifen users more often had node-positive contralateral disease (P= 0.045). In conclusion, metachronous CBCs developing after 1-3 years of tamoxifen treatment are more often ER-negative breast cancers. So far this does not seem to have a major impact on survival.