Yoanna S Pumpalova1, Oluwatosin A Ayeni2,3,4, Wenlong Carl Chen2,5,6, Ines Buccimazza2,7, Sharon Cačala2,8, Laura W Stopforth2,9, Hayley A Farrow9, Witness Mapanga2,10, Sarah Nietz5,7, Boitumelo Phakathi2,7, Maureen Joffe2,3,4, Valerie McCormack11, Judith S Jacobson12,13, Katherine D Crew1,12, Alfred I Neugut1,12,13, Paul Ruff2,3,10, Herbert Cubasch2,4,7, Daniel S O'Neil14. 1. Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA. 2. Noncommunicable Diseases Research Division, Wits Health Consortium (PTY) Ltd, Johannesburg, South Africa. 3. SAMRC/Wits Developmental Pathways to Health Research Unit, Department of Paediatrics, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa. 4. South Africa Medical Research Council Common Epithelial Cancers Research Centre, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa. 5. National Cancer Registry, National Health Laboratory Service, Johannesburg, South Africa. 6. Sydney Brenner Institute for Molecular Bioscience, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa. 7. Department of Surgery, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa. 8. Department of Specialized Surgery, Inkosi Albert Luthuli Central Hospital, Durban and Ngwelezane Hospital, Empangeni, University of KwaZulu-Natal, Empangeni, KwaZulu-Natal, South Africa. 9. Departments of Surgery and Radiation Oncology, Grey's Hospital, University of KwaZulu-Natal, Pietermaritzburg, KwaZulu-Natal, South Africa. 10. Division of Medical Oncology, Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa. 11. Environment and Lifestyle Epidemiology Branch, International Agency for Research on Cancer (IARC/WHO), Lyon, France. 12. Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA. 13. Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA. 14. Sylvester Comprehensive Cancer Center and Department of Medicine, Miller School of Medicine, University of Miami, Miami, FL, USA.
Abstract
BACKGROUND: In high-income settings, delays from breast cancer (BC) diagnosis to initial treatment worsen overall survival (OS). We examined how time to BC treatment initiation (TTI) impacts OS in South Africa (SA). METHODS: We evaluated women enrolled in the South African BC and HIV Outcomes study between July 1, 2015 and June 30, 2019, selecting women with stages I-III BC who received surgery and chemotherapy. We constructed a linear regression model estimating the impact of sociodemographic and clinical factors on TTI and separate multivariable Cox proportional hazard models by first treatment (surgery and neoadjuvant chemotherapy (NAC)) assessing the effect of TTI (in 30-day increments) on OS. RESULTS: Of 1260 women, 45.6% had upfront surgery, 54.4% had NAC, and 19.5% initiated treatment >90 days after BC diagnosis. Compared to the surgery group, more women in the NAC group had stage III BC (34.8% vs 81.5%). Living further away from a hospital and having hormone receptor positive (vs negative) BC was associated with longer TTI (8 additional days per 100 km, P = .003 and 8 additional days, P = .01, respectively), while Ki67 proliferation index >20 and upfront surgery (vs NAC) was associated with shorter TTI (12 and 9 days earlier; P = .0001 and.007, respectively). Treatment initiation also differed among treating hospitals (P < .0001). Additional 30-day treatment delays were associated with worse survival in the surgery group (HR 1.11 [95%CI 1.003-1.22]), but not in the NAC group. CONCLUSIONS: Delays in BC treatment initiation are common in SA public hospitals and are associated with worse survival among women treated with upfront surgery.
BACKGROUND: In high-income settings, delays from breast cancer (BC) diagnosis to initial treatment worsen overall survival (OS). We examined how time to BC treatment initiation (TTI) impacts OS in South Africa (SA). METHODS: We evaluated women enrolled in the South African BC and HIV Outcomes study between July 1, 2015 and June 30, 2019, selecting women with stages I-III BC who received surgery and chemotherapy. We constructed a linear regression model estimating the impact of sociodemographic and clinical factors on TTI and separate multivariable Cox proportional hazard models by first treatment (surgery and neoadjuvant chemotherapy (NAC)) assessing the effect of TTI (in 30-day increments) on OS. RESULTS: Of 1260 women, 45.6% had upfront surgery, 54.4% had NAC, and 19.5% initiated treatment >90 days after BC diagnosis. Compared to the surgery group, more women in the NAC group had stage III BC (34.8% vs 81.5%). Living further away from a hospital and having hormone receptor positive (vs negative) BC was associated with longer TTI (8 additional days per 100 km, P = .003 and 8 additional days, P = .01, respectively), while Ki67 proliferation index >20 and upfront surgery (vs NAC) was associated with shorter TTI (12 and 9 days earlier; P = .0001 and.007, respectively). Treatment initiation also differed among treating hospitals (P < .0001). Additional 30-day treatment delays were associated with worse survival in the surgery group (HR 1.11 [95%CI 1.003-1.22]), but not in the NAC group. CONCLUSIONS: Delays in BC treatment initiation are common in SA public hospitals and are associated with worse survival among women treated with upfront surgery.
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