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Original Article |

Delay in Surgical Treatment and Survival After Breast Cancer Diagnosis in Young Women by Race/Ethnicity

Erlyn C. Smith, MD; Argyrios Ziogas, PhD; Hoda Anton-Culver, PhD
JAMA Surg. 2013;148(6):516-523. doi:10.1001/jamasurg.2013.1680.
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Importance Breast cancer in women between the ages of 15 and 39 years (adolescents and young adults [AYAs]) constitutes 5% to 6% of all breast cancer cases in the United States. Breast cancer in AYA women has a worse prognosis than in older women. Five-year survival rates are lowest for AYA women, and only a few studies have examined the impact of delay in treatment, race/ethnicity, and other socioeconomic factors on survival in AYA women.

Objective To examine the impact of treatment delay time (TDT), race/ethnicity, socioeconomic status, insurance status, cancer stage, and age on the survival from breast cancer among AYA women.

Design, Setting, and Participants This is a retrospective case-only study of 8860 AYA breast cancer cases diagnosed from 1997 to 2006 using the California Cancer Registry database.

Exposure Treatment delay time was defined as the number of weeks between the date of diagnosis and date of definitive treatment. Kaplan-Meier estimation was used to generate survival curves, and a multivariate Cox proportional hazards regression model was performed to assess the association of TDT with survival while accounting for covariates (age, race/ethnicity, socioeconomic status, insurance status, cancer stage [American Joint Committee on Cancer], tumor markers, and treatment).

Main Outcomes and Measures Five-year survival rates for breast cancer as influenced by host factors, tumor factors, and TDT.

Results Treatment delay time more than 6 weeks after diagnosis was significantly different (P < .001) between racial/ethnic groups (Hispanic, 15.3% and African American, 15.3% compared with non-Hispanic white, 8.1%). Women with public or no insurance (17.8%) compared with those with private insurance (9.5%) and women with low socioeconomic status (17.5%) compared with those with high socioeconomic status (7.7%) were shown to have TDT more than 6 weeks. The 5-year survival in women who were treated by surgery and had TDT more than 6 weeks was 80% compared with 90% (P = .005) in those with TDT less than 2 weeks. In multivariate analysis, longer TDT, estrogen receptor negative status, having public or no insurance, and late cancer stage were significant risk factors for shorter survival.

Conclusions and Relevance Young women with breast cancer with a longer TDT have significantly decreased survival time compared with those with a shorter TDT. This adverse impact on survival was more pronounced in African American women, those with public or no insurance, and those with low SES.

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Figures

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Figure 1. Five-year survival by treatment delay time (TDT) and treatment modality. A, Survival of young women with breast cancer based on TDT, with number of patients at risk (log-rank, P = .005). B, Survival of young women with breast cancer who underwent surgery only based on TDT, with number of patients at risk (log-rank, P = .002). C, Survival of young women with breast cancer who underwent surgery and neoadjuvant chemotherapy based on TDT, with number of patients at risk (log-rank, P = .91). D, Survival of young women with breast cancer who underwent surgery and chemotherapy after surgery based on TDT, with number of patients at risk (log-rank, P = .30).

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Figure 2. Five-year survival by race/ethnicity, insurance status, and socioeconomic (SES) status among patients with treatment delay time (TDT) more than 6 weeks. A, Survival of young women with breast cancer with TDT more than 6 weeks based on race, with number of patients at risk (log-rank, P < .001). B, Survival of young women with breast cancer with TDT more than 6 weeks based on SES, with number of patients at risk (log-rank, P < .001). C, Survival of young women with breast cancer with TDT more than 6 weeks based on insurance, with number of patients at risk (log-rank, P = .03).

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