title: Time to adjuvant chemotherapy for breast cancer in National Comprehensive Cancer Network institutions.
abstract: BACKGROUND
  High-quality care must be not only appropriate but also timely. We assessed time to initiation of adjuvant chemotherapy for breast cancer as well as factors associated with delay to help identify targets for future efforts to reduce unnecessary delays.
  
  
  METHODS
  Using data from the National Comprehensive Cancer Network (NCCN) Outcomes Database, we assessed the time from pathological diagnosis to initiation of chemotherapy (TTC) among 6622 women with stage I to stage III breast cancer diagnosed from 2003 through 2009 and treated with adjuvant chemotherapy in nine NCCN centers. Multivariable models were constructed to examine factors associated with TTC. All statistical tests were two-sided.
  
  
  RESULTS
  Mean TTC was 12.0 weeks overall and increased over the study period. A number of factors were associated with a longer TTC. The largest effects were associated with therapeutic factors, including immediate postmastectomy reconstruction (2.7 weeks; P < .001), re-excision (2.1 weeks; P < .001), and use of the 21-gene reverse-transcription polymerase chain reaction assay (2.2 weeks; P < .001). In comparison with white women, a longer TTC was observed among black (1.5 weeks; P < .001) and Hispanic (0.8 weeks; P < .001) women. For black women, the observed disparity was greater among women who transferred their care to the NCCN center after diagnosis (P (interaction) = .008) and among women with Medicare vs commercial insurance (P (interaction) < .001).
  
  
  CONCLUSIONS
  Most observed variation in TTC was related to use of appropriate therapeutic interventions. This suggests the importance of targeted efforts to minimize potentially preventable causes of delay, including inefficient transfers in care or prolonged appointment wait times.
authors.affiliation: Outcomes Research Group, National Comprehensive Cancer Network, Fort Washington, PA, USA. jvandergrift78@gmail.com
authors.forename: Jonathan L
authors.initials: JL
authors.lastname: Vandergrift
authors.forename: Joyce C
authors.initials: JC
authors.lastname: Niland
authors.forename: Richard L
authors.initials: RL
authors.lastname: Theriault
authors.forename: Stephen B
authors.initials: SB
authors.lastname: Edge
authors.forename: Yu-Ning
authors.initials: YN
authors.lastname: Wong
authors.forename: Loretta S
authors.initials: LS
authors.lastname: Loftus
authors.forename: Tara M
authors.initials: TM
authors.lastname: Breslin
authors.forename: Clifford A
authors.initials: CA
authors.lastname: Hudis
authors.forename: Sara H
authors.initials: SH
authors.lastname: Javid
authors.forename: Hope S
authors.initials: HS
authors.lastname: Rugo
authors.forename: Samuel M
authors.initials: SM
authors.lastname: Silver
authors.forename: Eva M
authors.initials: EM
authors.lastname: Lepisto
authors.forename: Jane C
authors.initials: JC
authors.lastname: Weeks
mesh_terms: D000328:Adult; D001741:Black or African American / Q000706:statistics & numerical data; D000368:Aged; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000008:administration & dosage*; D001943:Breast Neoplasms / Q000188:drug therapy* / Q000191:economics / Q000473:pathology / Q000601:surgery*; D002173:Cancer Care Facilities / Q000706:statistics & numerical data*; D017024:Chemotherapy, Adjuvant / Q000592:standards; D015986:Confounding Factors, Epidemiologic; D004334:Drug Administration Schedule; D005260:Female; D054625:Healthcare Disparities / Q000706:statistics & numerical data; D006801:Humans; D007348:Insurance, Health; D008197:Lymph Node Excision; D008279:Magnetic Resonance Imaging; D016462:Mammaplasty; D008408:Mastectomy / Q000379:methods; D008484:Medicaid; D006278:Medicare; D008875:Middle Aged; D009367:Neoplasm Staging; D012017:Referral and Consultation; D013997:Time Factors; D014481:United States; D044465:White People / Q000706:statistics & numerical data