Waiting time for breast cancer surgery in Quebec

BACKGROUND: Currently there is no agreement on the optimal time to treatment of breast cancer; however, given the considerable emphasis on early detection, one would expect a similar emphasis on early treatment. The purpose of our study was to assess the time interval to surgery from initiation of diagnosis among Quebec women with breast cancer and to examine the influence on waiting time of age, pattern of care and cancer stage. METHODS: Records of physician fee-for-service claims and of hospital admissions were obtained for all Quebec women who underwent an invasive procedure for the diagnosis or treatment of breast cancer between 1992 and 1998. Waiting time was calculated as the number of days between the first diagnostic procedure and surgical treatment. RESULTS: There were 29 606 episodes of breast cancer surgery among 28 100 women: 5922 mastectomies and 23 684 lumpectomies. The absolute number of episodes of breast cancer treated with surgery rose from 3626 in 1992 to 5162 in 1998. The overall median waiting time was 34 days (interquartile range [IQR] 19–62); 13.5% of the women waited longer than 90 days. The median waiting time rose from 29 days (IQR 15–54) in 1992 to 42 days (IQR 24–72) in 1998, representing a relative increase of 37% (95% confidence interval [CI] 32%–43%) after adjusting for age and cancer stage. The median waiting time increased with the number of diagnostic procedures, from 24 days (IQR 14–42) with 1 procedure to 48 days (IQR 27–84) with 3 procedures to 72 days (IQR 43–121) with 4 procedures, representing adjusted relative increases of 97% (95% CI 91%–103%) and 194% (95% CI 181%–208%), respectively. The proportion of women receiving 3 or more diagnostic procedures before surgery increased steadily over the study period, from 19.2% in 1992 to 33.0% in 1998. The median waiting time was shorter with more advanced stages of cancer: 53 days (IQR 30–86) for carcinoma in situ, 35 (IQR 20–62) for localized disease, 28 (IQR 16–49) for regional disease and 24 (IQR 11–52) for disseminated disease. INTERPRETATION: Waiting time between initial diagnosis and first surgery for breast cancer has increased substantially in Quebec between 1992 and 1998. Possible explanations include increased demand, decreased resources and changes in patterns of care.

背景：目前对于乳腺癌（breast cancer）的最优治疗时机尚无统一定论；鉴于学界对早期筛查的高度重视，理应同步强调早期治疗。本研究旨在评估加拿大魁北克省乳腺癌女性患者从启动诊断到接受手术的时间间隔，并考察年龄、诊疗模式与癌症分期对等待时长的影响。
方法：本研究纳入1992年至1998年间，所有在魁北克省接受针对乳腺癌诊断或治疗的侵入性操作的女性患者，收集其医师按服务收费索赔记录与住院收治数据。等待时长定义为首次诊断性操作至外科手术治疗之间的天数。
结果：本研究共纳入28100名女性患者，累计完成29606例乳腺癌手术：其中乳房切除术（mastectomy）5922例，乳房肿瘤切除术（lumpectomy）23684例。接受手术治疗的乳腺癌病例数从1992年的3626例稳步增长至1998年的5162例。整体中位等待时长为34天（四分位距[interquartile range, IQR] 19–62天），13.5%的患者等待时长超过90天。中位等待时长从1992年的29天（IQR 15–54天）升至1998年的42天（IQR 24–72天）；在校正年龄与癌症分期后，相对增幅达37%（95%置信区间[confidence interval, CI] 32%–43%）。中位等待时长随诊断性操作次数增加而延长：仅接受1次诊断操作的患者中位等待时长为24天（IQR 14–42天），3次操作的患者为48天（IQR 27–84天），4次及以上操作的患者为72天（IQR 43–121天）；在校正后，上述两组的相对增幅分别为97%（95%CI 91%–103%）与194%（95%CI 181%–208%）。手术前接受3次及以上诊断操作的患者比例在研究期内持续上升，从1992年的19.2%增至1998年的33.0%。不同癌症分期的患者中位等待时长存在差异：原位癌（carcinoma in situ）患者为53天（IQR 30–86天），局限性癌症患者为35天（IQR 20–62天），区域性癌症患者为28天（IQR 16–49天），播散性癌症患者为24天（IQR 11–52天），即癌症分期越晚，中位等待时长越短。
解读：1992年至1998年间，魁北克省乳腺癌患者从首次诊断到首次手术的等待时长显著延长。可能的解释包括诊疗需求增加、医疗资源缩减以及诊疗模式的转变。