Effect on survival of delays in referral of patients with breast-cancer symptoms: a retrospective analysis

Summary

Background

From April 1, 1999, family physicians are required to refer all patients who have suspected breast cancer in the UK urgently to hospital, to be seen within 14 days of referral. We investigated whether delays by providers in routine practice for diagnosis influence survival.

Methods

We did a retrospective analysis of 36 222 patients with breast cancer listed in the Yorkshire Cancer Registry. Data on delay after family-physician referral, hospital visit, and start of treatment were available, as well as on tumour grade and stage of presentation.

Results

There was no evidence that provider delays of longer than 90 days adversly influenced survival. The time from family-physician referral to first hospital visit changed little (median 10 vs 13 days) from 1976 to 1995, whereas time from first visit to first treatment doubled (7 vs 13 days). More than 8% of patients younger than 50 years delayed longer than 90 days, compared with 3% of patients older than 50 years (p<0·001). 48% of younger patients had their first treatment within 30 days compared with 64% of those older than 50 (p<0·001). The survival for 5708 patients diagnosed in 1986–90 selected for survival analysis was 63% at 5 years, and 51% at 8 years. Patients who presented early and were treated in less than 30 days had significantly worse outcomes (p<0·001).

Interpretation

Delays by providers in diagnosis of 3 months or more do not seem to be associated with decreased survival in patients presenting with breast cancer. The drive for all women with possible breast cancer to be seen within 14 days will divert resources from other services and is not supported by this study.

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.