title: Missed opportunities: clinical antecedents in the diagnosis of advanced breast cancer.
abstract: BACKGROUND
  Locally advanced breast cancer (LABC) often requires complex treatment, and the prognosis is typically poor. We hypothesize that LABC patients engage the healthcare system with a variant pattern as compared with patients diagnosed with early stage disease.
  
  
  METHODS
  We identified all newly diagnosed breast cancer patients between 2005 and 2009 at Kings County Hospital (KCH), focusing upon established patients. All provider encounters during 2 years before diagnosis were retrieved from the medical record. Patients were stratified to two groups: early breast cancer (n = 87) and LABC (n = 44). Encounters were classified by type of clinic and whether a clinical breast examination or breast imaging study was performed.
  
  
  RESULTS
  The early group made more total contacts with the healthcare system than LABC group, 10.4 and 7.4, respectively. Both groups demonstrated statistically equivalent rates of contact with subspecialty and acute providers. Early patients demonstrated greater usage of primary care services, 4.6 compared with 3.0 visits among LABC patients. The early cohort demonstrated increased rates of breast imaging and examinations overall as well as an increased rate of breast examination within primary care clinics.
  
  
  CONCLUSIONS
  Delayed breast cancer diagnosis is influenced by patterns of healthcare utilization and the effectiveness of primary care services. LABC patients are less likely to visit primary care clinics despite frequent contacts with the healthcare system and as such are less likely to receive basic diagnostic procedures, including clinical breast examination and mammography. Renewed attention to these primary care activities should detect many LABC patients at an earlier stage.
authors.affiliation: Department of Surgery, State University of New York Downstate Medical Center, Brooklyn, NY, USA. tcarter18@gmail.com
authors.forename: Timothy I
authors.initials: TI
authors.lastname: Carter
authors.forename: James J
authors.initials: JJ
authors.lastname: Reilly
mesh_terms: D001943:Breast Neoplasms / Q000473:pathology* / Q000601:surgery; D018270:Carcinoma, Ductal, Breast / Q000473:pathology* / Q000601:surgery; D055088:Early Detection of Cancer / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D008327:Mammography / Q000706:statistics & numerical data; D009367:Neoplasm Staging; D010342:Patient Acceptance of Health Care; D011320:Primary Health Care / Q000706:statistics & numerical data*; D014932:Women's Health Services / Q000706:statistics & numerical data*