Being diagnosed with breast cancer can lower a patient’s quality of life. A long waiting time for surgery will certainly cause stress and anxiety (14) and can deepen the spread of the tumor. There is no fixed waiting time from diagnosis to surgery, but it’s recommended once the diagnosis is made to start the surgery as quickly as possible. However, it’s important to note that international comparisons must be interpreted with caution, because of the different definitions of waiting times before treatment, the methodologies used and above all because of the complexity and diversity of the management strategies in each healthcare system (15).
In our study the sample consisted of 77 women. Ten waiting times have been calculated. The most important: The Global time to first treatment (surgical treatment) was 78.5 days with an interquartile range (IIQ) of [55.5-113.25 days]. The information period was 10 days with an IIQ of [3–19 days] and the global time of access to surgery was 43.5 days with an IIQ of [40-54.75].
Estimating waiting times to surgery can help countries follow the efficacy of their healthcare system for cancer patients, and to increase awareness of effective and timely care. The first intermediate time (the waiting time to access to the diagnosis), varies between 13 days according to the studies of Limam et al (15), Poucel et al (8), Rayson et al (16) and 22 days in the study of Revaux et al (9). According to international recommendations this period should not exceed 28 days. Compared to previous studies, the 8-day timeframe found in our study is the shortest. The second intermediate time (the waiting time to access to first treatment (surgery), was unfortunately the highest. In literature, it was around 12 days in the study of Revaux et al. (9), 22.9 days in the study of Poucel et al (8) and 29 days in the study of Alberta in Canada (17). Regarding the global waiting time to surgery which is surgery, according to the literature, it varied between 10 days to 52 days (7,15,18). According to the National Institute of Health and Clinical Excellence (NICE) (19), the British Association of Oncology (BASO) (20) and the National Health Service Cancer Plan 2000 (21), the HAS recommended maximum waiting time is 4 weeks and indeed 90% of the patients were able to access to treatment within this timeframe. (22) In our study, only one patient had surgery within the first month after diagnosis.
To avoid inconsistent patients care management, it is important to analyze the patient care pathway and create a structured process especially with the increasing complexity of breast cancer treatment. The main goals of establishing a care pathway consist of improving the quality of care, reducing risks and monitoring patient waiting times before surgical treatment (23). Moreover, to be effective, the healthcare system must measure and evaluate how long it takes for the patient to get through all the steps needed to finalize her treatment in order to ensure the best quality services (17). In addition, waiting times evaluation is not just a direct reflection of internal managing systems but also of continuity of care and coordination between several care providers (24). Nonetheless, the continuous growing complexity of the patient care trajectory reveals more and more inequalities to care access. Several waiting periods are calculated considering the patient care trajectory and the most important ones, which can cause problems and directly influence delays, are: the appointment time. It starts from the first patient’s contact with the healthcare system to the first consultation. Appointment waiting time represents “the system delay” and should be distinguished from the “patient delay” which starts from the day of symptoms onset to the first patient contact with the healthcare system.
There are no standards defining the optimal appointment time. In fact, this time varies a lot in the literature. The National Health Service Cancer Plan recommends a maximum of two weeks for the first consultation for 93% of cases (8). The European Society of Surgical Oncology (ESSO) recommends that 80% of urgent cases referred must be seen by a specialist within 5 days, and 70% of non-urgent cases must be seen within 15 days (25). The British Association of Surgical Oncology (BASO) (20) recommends for 90% of patients to not exceed two weeks for urgent cases and three weeks if the situation is considered less urgent. Despite the fact that 75 out of the 77 women in our study have had a mammogram before the first consultation which was suspicious in 92.2%, only 52.3% of them had an appointment in less than two weeks. This long waiting time for the first appointment with a specialist for breast cancer patients compared to the literature, could be explained by several factors. For example, the healthcare professionals dealing with appointment schedules are not sufficiently qualified to estimate the urgency and severity of the situation. Also, the general practitioner or the midwife who refers the patient, do not emphasize enough in their referral letter on the suspicious diagnosis of breast cancer.
The second important time is the waiting time to diagnosis between the first and the last consultation (diagnosis formulation). This time frame calculated for all our patients (N = 77) has a median of 9 days with an interquartile range of [0–28.5 days].
In reference to this time, NHS England is working towards a new target called the Faster Diagnosis Standard (FDS). The objective is that the patient should not wait for more than 28 days from referral to finding out whether he or she has cancer. This process is meant to ensure that patients do not have to wait too long to find out their diagnosis (19,26). Delays in breast cancer care, and waiting for definitive diagnosis after an abnormal screening mammogram is an intense and often agonizing experience for women involved and for their families (27). In our study, 40, 3% of cases have had an immediate decision, which means that in the first consultation the diagnosis has been formulated, whereas 59,7 % required two consultation or more. Moreover, the specialist may need to do a variety of investigations in order to obtain the final diagnosis or to eliminate differential diagnoses in case the patient has not done the mammogram, but comparing to the first EUSOMA preoperative quality indicator related to clinical pathways and care access in breast cancer (proportion of women with breast cancer who pre-operatively underwent mammography, ultrasound and physical examination) who required a minimum standard of 90% and a target of 95%, our result is satisfactory (28). Also we found that 79.2% of the patients with suspected radiological diagnosis pre-operatively underwent biopsy to confirm the diagnosis.
With regard to the multidisciplinary discussion, it is one of the internal organization criteria of the service that brings together qualified health professionals from different disciplines to make a decision for the definitive diagnosis based on the radiological and the anatomopathological results. The National Institute for Clinical Excellence recommends multidisciplinary discussion at some point during the care process. Files examination during a multidisciplinary committee is in itself a guarantee not only of the best treatment option chosen but also of the quality of care (19). The management of breast cancer by a multidisciplinary team seems to be associated with a significant improvement in the survival rate (29). In our study, this time (the waiting time to the multidisciplinary discussion) was calculated for all the women. Due to the increasing complexity of breast cancer patient management and the cancer care paradigm change from a disease-focused management to a patient centered approach, having multidisciplinary staff become an key factor in quality indicators (30). Besides, according to Héquet D et al discussing breast cancer cases in multidisciplinary meetings can lead to changes in surgical management recommendations in 12 to 52% of cases (31). In the current study, most women (80.5%) had to wait between 1 to 7 days for their files to be discussed during the multidisciplinary meeting, only 9.1% of files were discussed the same day the diagnosis was made. In our study, we have considered the time between the multidisciplinary discussion (in which a final decision was made regarding the surgical procedure) and the date the patient was informed of this decision. Our results highlighted a dysfunction in this process in reference to when, how and by whom the patients were informed. In fact, patients had to contact themselves the department to obtain any information relative to their appointment and if the patient forgets to contact the service, she will miss her surgical appointment. In our department, a nurse was charged to inform the patient of the date of the operation, without any extra information about the type of surgery. International recommendations suggest that the attending physician should announce the final diagnosis after having discussed the file with a multidisciplinary team, in a special announcement and information consultation, in which the surgeon takes time to answer the patient's questions (19). Actually, proper diagnoses announcement and clear and simplified information decrease significantly psychological morbidity by reducing anxiety and complains, and increasing treatment adherence (19). Considering the patient’s information process in our setting, we suggest that the nurse should play a crucial role in facilitating the patient’s journey through the surgical pathway, like Saint-Augustinus Hospital experience in Belgium who introduced in 2005 a specialized nurse to facilitate the patient’s journey through the multidisciplinary track and to be a gate keeper of the clinical pathway is an example to follow (32).
In our study, we have also considered waiting times from diagnosis to surgery (the global waiting time of access to surgery). This is a global time between the multidisciplinary discussion (date of the decision to treat) and surgery (treatment) which give us an idea about delays to undergo the surgery. Although, there are no standard guidelines defining the appropriate time from diagnosis to surgery for patient with breast cancer, it is obviously recommended to accelerate treatment once the diagnosis is made. The median of this time was 43.5 days with an interquartile range of [40–54.75 days]. Almost half of the women (48.1%) needed at least one to two months to undergo surgery. Only eight women (10.4%) had to wait for less than one month which is higher than reported in several studies. Studies in France reported this waiting time to be between 13.5 and 22.9 days (8,9). It was around 17 days in Canada (32) and 30 days in the United States (33). Cancer Care Ontario recommends a maximum period of 28 days between the decision to treat and surgery for invasive breast cancer (9). The UK National Health Service (NHS) recommendations pointed out that time between diagnosis and first treatment should not exceed 31 days (34). Based on “Guidelines for the management of symptomatic Breast cancer”, this waiting time between the decision to treat and the surgery should not exceed two weeks (20).
The WHO (35) defines quality of care as "the extent to which health care services provided to individuals and patient populations improve desired health outcomes. In order to achieve this, health care must be safe, effective, timely, efficient, equitable and people-centered". The time to care, in its various components, is an important quality indicator and a crucial element that can condition patient’s prognosis, particularly those with breast cancer. Reducing these delays in providing care must be integrated into a continuous quality improvement approach where decision-making is based on evidence-based data to take appropriate corrective actions. Surgery spans the entire cancer continuum, as it is often required for diagnosis, staging, treatment or palliation. It is usually one of the first contact points of the patient with the cancer care system and 80% of cancer patients can expect to undergo surgical intervention. A well organized pathway can improve quality of care and significantly reduce waiting time.