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Ciência & Saúde Coletiva

Print version ISSN 1413-8123On-line version ISSN 1678-4561

Ciênc. saúde coletiva vol.20 no.12 Rio de Janeiro Dec. 2015

http://dx.doi.org/10.1590/1413-812320152012.00422015 

ARTICLE

Breast cancer: diagnosis-to-treatment waiting times for elderly women at a reference hospital of São Paulo, Brazil

Camila Brandão Souza1 

Suzete Maria Fustinoni1 

Maria Helena Costa Amorim2 

Eliana Zandonade2 

Jéssica Carvalho Matos1 

Janine Schirmer1 

1Escola Paulista de Enfermagem, Universidade Federal de São Paulo. R. Napoleão de Barros 754, Vila Clementino. 04024-002 São Paulo SP Brasil. ufesmila_enfer@yahoo.com.br

2Programa de Pós-Graduação em Atenção à Saúde Coletiva, Universidade Federal do Espírito Santo.Brasil


Abstract

This study compares waiting time from diagnosis of breast cancer to start of treatment with patients’ social-demographic and clinical profiles in women aged 60 or more at the PérolaByington Hospital, São Paulo, over the years 2001–2006.It is a descriptive study based on secondary data in a sample of 1,299 cases. Social-demographic, clinical and temporal variables were collected. Patients were divided into two groups: those with period between diagnosis and start of treatment less than 60 days, and greater than 60 days. The average time between diagnosis and start of treatment was 74.7 days (SD = 212.6), and the median time was 45 days. This waiting time was lower for subjects without diagnosis and without prior treatment (p = 0.001), and also for those with tumors at Stage 0, in situ or Stage I(p = 0.001). Time was significant for the outcomes of relapse (p = 0.004) and metastasis (p = 0.038). Having established diagnosis and treatment also resulted in lower time to start of the required care. Improvement to the structuring and functioning of the health service is an essential need, for dealing with the cases of the disease in an efficient manner, an important challenge for Brazil’s Unified Health System.

Key words: Breast cancer; Mammary neoplasia; Elderly women; Treatment; Diagnosis; Delay

Resumo

Objetivou-se analisar o tempo entre o diagnóstico e o início do tratamento e conhecer o perfil sociodemográfico e clínico de mulheres com 60 ou mais anos de idade, diagnosticadas com câncer de mama entre os anos de 2001 a 2006, no Hospital Pérola Byington, São Paulo. Trata-se de um estudo descritivo, com dados secundários e amostra de 1299 casos. Coletou-se variáveis sociodemográficas, clínicas e temporais. Formou-se dois grupos de mulheres utilizando a variável tempo, sendo o tempo entre o diagnóstico e o início do tratamento: “até e maior que 60 dias”. A média do tempo entre o diagnóstico e o início do tratamento foi de 74,7 dias (DP = 212,6), e o tempo mediano de 45 dias. As idosas sem o diagnóstico e sem o tratamento anterior levaram menos tempo para dar início ao tratamento (p = 0,001), bem como as mulheres com estadiamento do tumor na fase inicial, in situ e I (p = 0,001). O tempo foi significante para os desfechos de recidiva (p = 0,004) e metástase (p = 0,038). O diagnóstico e o tratamento estabelecidos garantiu às idosas menor tempo para o início da assistência devida. Melhorar a estruturação e o funcionamento dos serviços de saúde constitui fator imprescindível para o atendimento dos casos da doença de forma eficiente, um importante desafio para o Sistema Único de Saúde.

Palavras-Chave: Neoplasias da mama; Idosa; Tratamento; Diagnóstico; Atraso

Introduction

Breast cancer is the most common cause of death among women and, with the exception of non-melanoma skin cancer, is the most frequently occurring type of cancer in 140 countries1. In Brazil, a total of 57,120 new cases were estimated for the years 2014 and 2015, with an estimated risk of 56.09 cases for each 100,000 women2. For the same period the forecast is 30,740 new cases in Brazil’s Southeastern region alone1.

The increase in the occurrence of cancer is not only due to increased life expectancy, but is also related to the improvement in diagnostic technology, and the expansion of surveillance programs3. In the developed countries its frequency is greater, and could also be related to more advanced records, and sedentary and reproductive habits4. The mortality coefficients are higher in the developing countries1, a reflection of inequalities in health5.

Breast cancer progresses slowly and, if diagnosed early, the possibility of cure or prolongation of survival is considerably increased6. It is rare before the age of 35, but above this age group its incidence is rapid, growing and progressive7. Almost four out of every five cases takes place after the age of 502.

In the United States, in 2005, half of the patients diagnosed with breast cancer were over 65; and in 2015 it is estimated that this percentage will increase by 30%8. Populations with higher life expectancy, such as Switzerland, have the highest prevalence of this type of cancer in Europe, with old people representing 12% of that country’s total cases9.

Studies on the interval between diagnosis and start of treatment are important for deciding resolution measures. In Brazil there are tools, such as theRegistro de Câncer de Base Populacional (RCBP) and theRegistro Hospitalar de Câncer (RHC), which help in monitoring and evaluation of action for control and research on cancer, as well as helping indecisions on evaluation of the effects of treatments and control of the variables recorded for each tumor10,11. Information in the RHCs has provided input for several studies12-14, and analyses of time trends of the phenomena associated with the disease11.

The delay between diagnosis and start of treatment worsens breast cancer, making it progressive and irreversible15. Responding to this, Law 12732, enacted in November 2012, gave cancer patients a legal right to start of treatment in a period of 60 days or less after confirmation of diagnosis16.

There are three components of delay in treatment of breast cancer: From the moment when the woman presents symptoms until her arrival at the health service; between attended by a doctor and her first access to specialized care for confirmation of the diagnosis; and finally between that access/diagnosis and the start of treatment17. Any individual patient may suffer delays in various phases of her diagnosis and treatment15.

Access, and the time for diagnosis and treatment of this type of cancer vary, depending on geographical and socio-economic factors15. Delay can adversely affect prognosis, reducing the chances of cure, due to the growth of the tumor15,18-20. There is an association between delay from diagnosis to treatment and shorter progression-free survival, lymph node metastasis, the size of the tumor, and its staging21. On the other hand early detection is related to higher rates of cure21,22.

The law guaranteeing cancer patients treatment in up to 60 days after diagnosis is recent16, while networks to promote control of cancer have existed for longer23. The consolidation of the concept of Network as a strategy for managing oncological care in Brazil emerged in 2003. Brazil’s National Cancer Institute – INCA (the Instituto Nacional de Câncer José Alencar Gomes da Silva), in partnership with the Health Ministry, planned a common agenda for actions to control cancer, involving various spheres of society, aiming to reduce cancer incidence and mortality in the population and assure quality of life for patients and their families. One of its aims was to strengthen planning and assessment of actions for oncological care, stimulating integration of this care in the health system and optimization of resources23. The Network possibly improves the effectiveness of breast cancer treatment in Brazil, helping in early diagnosis, and reduction of delays between diagnosis and treatment, because it is an indicator of efficacy and of the efficiency of the Service in all the phases of treatment of breast cancer.

With all the above in mind, this study analyzes time between diagnosis and start of treatment in elderly women diagnosed with breast cancer over the years 2001–2006, at a r service in São Paulo, São Paulo State, Brazil, and to discover the profile of these elderly women in terms of initial staging, primary location, tumor histological type, relapse, metastasis and treatments given.

Methodology

This is a descriptive study, with secondary data. The population was constituted as all the cases occurring of elderly women with diagnosis of breast cancer who received treatment at the Pérola Byington Hospital, Women’s Health Reference Center, in the municipality of São Paulo, over the period January 2001 to December 2006, registered in the Health Information System of the Cancer Hospital Registry (SIS-RHC) – a total of 1,299 cases.

The Women’s Health Reference Center of the Pérola Byington Hospital, in the municipality of São Paulo, has the mission of providing outpatient and medical-hospital care, of reference quality, for the population of greater São Paulo, in the areas of human reproduction, and genital and mammary gynecology and oncology24.

This hospital’s level of therapy in mammary and gynecological cancer, among other activities, is gaining increasing recognition. It also maintains partnership activities with teaching institutions, and organizations in research, technology and community health education24.

Cases with incomplete records of the variables related to time were excluded (case records were examined to understand reasons for this non-completeness). In women with more than one diagnosis of primary breast cancer, only the first case was considered.

The age of 60 was adopted as a characteristic of being elderly, in accordance with the definition used by the Brazilian Geography and Statistic Institute (IBGE)25 and the National Policy for the Health of the Elderly26.

13 variables were analyzed, all taken from the Tumor Record File and from the RHC of the Hospital, with information on age at diagnosis, year of diagnosis, prior diagnosis and treatment, primary location of the tumor, histological type of the tumor, clinical stage of the tumor at diagnosis, treatment carried out and combinations, relapse, metastasis, location of the metastasis, time between first consultation and start of treatment, time between diagnosis and start of treatment, and time between first consultation and diagnosis. Data on the variables relapse and metastasis were followed for a period of five years.

The software used for statistical treatment of the data was: (i)Microsoft Office Excel 2007 for Windows, and (ii) the IBM statistical package SPSS Statistics 20.0. Univariate descriptive analysis was carried out on the data obtained to establish the pattern of distribution of women who sought treatment for breast cancer. The results were analyzed using calculations of frequency, mean, median and standard deviation. For the association between time and the variables of the study the chi-squared test of association was used.

Two groups of women were formed based on the variable time between diagnosis and start of treatment – divided into ‘up to 60 days’ and ‘more than 60 days’. A significance level of p ≤ 0.05 was adopted.

There are no financial and/or political conflicts of interest.

Results

In the years 2001–2006, 1,318 new cases of elderly women with breast cancer were attended at the Pérola Byington Hospital. A total of 19 cases were excluded because no type of treatment was carried out after the diagnosis, thus presenting non-completion of the time variable. This resulted in a total of 1,299 women.

In Table 1 it is seen that more than 50% of the women were in the 60–69 age group. The average age of the women was 70.1 years (standard deviation 7.3 years) and the median was 69 years. The highest frequency of diagnoses was in 2006, 22% of the universe of subjects. More than 90% arrived at the service without diagnosis and without prior treatment. In 98% of the cases the primary location of the breast tumor was imprecise. As to the histological type, 78% were infiltrating ductal carcinoma. Stage II was present in 44% of the subjects, and Stage III in 28%.

Table 1 Clinical and epidemiological profile of elderly women with breast cancer attended by the Pérola Byington Hospital. São Paulo, 2014. 

The association of surgery, chemotherapy, radiotherapy and hormone therapy was the most used by the institution in the treatments, at 26% of the total, followed by surgery, radiotherapy and hormone therapy, with 22%.

Table 2 shows that in the great majority of cases (92%), there was no relapse. There was metastasis in 17% of the women, the most frequent location being isolated in the bronchial tubes and lungs (26%), followed by bones, joints and joint cartilage of the arms or legs (23%).

Table 2 Profile of the variables relapse and metastasis in elderly people with breast cancer attended by the Pérola Byington Hospital. São Paulo, 2014. 

The average time between diagnosis and start of treatment was 74.7 days (SD = 212.6 days) and the median time was 45 days. The average time between the first consultation and diagnosis was 21 days (SD = 124.3 days). It was found that 5% of the women attended already having received the diagnosis, and that approximately 50% of the women had the date of diagnosis coinciding with the date of the first consultation. On average the elderly person waited 95.7 days (SD = 193.0 days) between the first consultation at the service and the start of treatment. The average time was 60 days.

Table 3 shows that more than 80% of the women attended had an interval of up to two months between the diagnosis and treatment, the majority waited one or two months, and approximately 36% were attended in up to one month.

Table 3 Statistics on time between diagnosis, first consultation and treatment of elderly women with breast cancer attended at the Pérola Byington hospital. São Paulo, 2014. 

* Patients with diagnosis prior to the consultation.

Table 4 shows that the most elderly women, aged 80 or more, had a lower time between diagnosis and treatment than women of age up to 69, but this variable did not show statistical significance.

Table 4 Association between time and epidemiological variables of elderly people with breast cancer attended by the Pérola Byington Hospital. São Paulo, 2014. 

In the last period of two years studied, there was a significant improvement (p = 0.001) in the time between diagnosis and treatment, compared to the pair of years 2002–3. In 2003, the majority of the elderly women received treatment after 60 days of diagnosis, and the contrary was true in the years 2005 and 2006.

Patients in the study who arrived at the hospital without diagnosis and without treatment took less time to start treatment than those that arrived with the diagnosis (p = 0.001). Receiving the diagnosis within the service itself favored access to the treatment.

Women with tumors at Stage 0 (in situ) or Stage I began treatment faster than those with the most advanced stage (III), p = 0.001.

Table 5 shows that time was significant for the outcomes of relapse and metastasis, with p = 0.004 andp = 0.038, respectively. Of the women who received care in up to 60 days, 6% had relapsed and 16% had metastases; among those who received care in more than 60 days, 12% had relapsed and 21% had metastases.

Table 5 Association between time and the variables relapse and metastasis in elderly people with breast cancer attended by the Pérola Byington Hospital. São Paulo, 2014. 

Discussion

The average time between diagnosis and start of treatment was 74.7 days, and median time was 45 days. Arriving at the service without diagnosis and with no previous treatment, and being at an initial stage, favored access to treatment. The time interval between diagnosis and start of treatment was significant for the outcomes of relapse and metastasis.

In this study there were 19 women who did not start the treatment. Reasons given included some commonly described in their medical records such as: ‘Belief in religion and that a miracle would happen’; ‘Lack of hope for a cure when at an advanced stage’; ‘Fear of confronting the illness and being mutilated’, and, ‘Patient returned to place of origin due to inability to pay the high cost of living in São Paulo’.

A study in Campinas found that abandonment of the treatment while it is in progress is common, and that the risk of abandoning the treatment is three times higher in elderly women with breast cancer than in women under age 5527. Another study showed that for hormone therapy, women below the age of 35 have a greater propensity to abandon treatment28.

There is a scarcity of work dealing only with elderly women, and some even opt to exclude them from the sample29,30, often due to the fact that they have factors concomitant with the basic illness, which can interfere in outcomes. A work on the profile of women with breast cancer, in the State of Espírito Santo, which included elderly women, also found a higher prevalence at age 60 to 69, among a group of only elderly people29. This group tended to respond well to the treatments, but after the age of 75 the prognosis was adverse for the cancer in question31.

The number of diagnoses in 2006 was almost twice that of 2001. This phenomenon may be due, not to the increase in the existence of cases but due to the improvement in diagnosis and the guarantee of accessibility to the service. The creation of the consensus document for monitoring of breast cancer3, in 2004, presented recommendations ranging from prevention of risk factors to palliative care, and was important for standardization of actions.

Women would usually arrive at the Service, on referral from the Primary Healthcare Unit, without confirmation of diagnosis, and without prior treatment. This contrasts with the situation at a philanthropic hospital, in the city of Vitória, in which the majority of the women attended already had the diagnosis and prior treatment32.

Imprecision in the recording of the primary location of the mammary tumor was an item of concern. Since it is necessary to the diagnosis, it should be filled in on the medical record and recorded by the records of the RHC, but at some point there was a failure in this process. Since this concerns people diagnosed with cancer, and because the process of becoming ill is one of long duration, which calls for an interaction between doctor and patient, appropriate filling in of the medical record should be facilitated33.

In developing countries recording the data is a complex task, due to the shortage of material and human resources. The risk of distortions is a fact10, and completeness is often at low levels11,33. However, there is availability of training and updating of professionals11,34, with a view to improvement in the quality of this recording.

As for the type of tumor, infiltrating carcinoma, or invasive ductal carcinoma, not otherwise specified (NOS), is the largest group of invasive carcinomas of the breast. It is a diagnosis of exclusion, which represents 75-80% of the invasive carcinomas35. These tumors offer a less favorable prognosis, when compared to the other invasive carcinomas35,36. Normally they present necrosis, areas of infarction and a characteristic central acellular area35.

Other surveys indicate similar results to the above, and to the present study, with predominance of infiltrating ductal carcinoma among the histological types studied37-40. It is important to note that patients with similar ages and tumors of the same histological type do not behave uniformly, and their developments are different38.

The histological type of a tumor is not a prerequisite for assessing Stage of the tumor which, when well defined, gives a correct direction to therapy, and is closely correlated with outcome41. If diagnosed and treated rapidly, breast cancer has a very significant cure rate21,22. Arrival at the health service while still in the initial phase of the illness is the great challenge for Brazil. As Silva32also found, there was significant relation between illness first attended at Stages II or III and the variables ‘low level of schooling’ and ‘origin of referral: SUS’ – in the case of this study, respectively 4.3 and 1.9 times greater than chance. Cintra et al.39 found a similar result when evaluating women of the city of Juiz de Fora (in the Brazilian State of Minas Gerais), and concluded from this that the focus should be on monitoring and surveillance of breast cancer, as well as guarantee of treatment when diagnosed. Srur-Rivero and Cartin-Brenes42 also found a similar distribution.

Evolution of breast cancer in elderly women seems to have a behavior similar to that of young women, however, with age, the same woman begins to have less access to monitoring programs, methods of diagnosis and more modern and complex treatments29.

The INCA, based on epidemiological data, proposes monitoring by clinical examination for all women over 40, independently of age group, and by mammography for women between 50 and 6943. It is observed that there is no consensus on checking for breast cancer in women under 50 and over 70. The U.S. Preventive Services Task Force44 recommends mammography every other year for women aged 50 to 74 – and that before age 50 it should be an individual decision, taking into account the cost-benefit of the procedure. There are no data that support its indication for women over the age of 75. For women of any age, self-examination of the breasts is not recommended, due to absence of evidence of its efficacy, and this absence also is the case for clinical examination of the breasts. According to the American Cancer Society45, clinical examination of the breasts should be carried out every three years in all women between 20 and 30, and every year in women above 40 – and after this age, there should be an annual mammography. The ACS also says that all women should know their breasts well, and clinical examination is important as from age 20. The Canadian Task Force46 does not recommend routine tracking with mammography for women between 40 and 49. It is recommended for each two to three years in women aged 50 to 69, and 70 to 74. As also argued by the U.S. Preventive Services Task Force, there is no confirmation of its efficacy for women above 7544,46. According to the European Guidelines, tracking by mammography should take place every two years, in the target group of women aged 50 to 6947. Authors argue that if the elderly woman has a life expectancy of more than five years, does not have any co-morbidities that are significant risks and has preserved cognition, routine tracking by mammography should be considered29.

Elderly women have less possibility of early diagnosis48. Diagnosis in the initial phases calls for less aggressive treatments, and mammography is the principal method of early detection that is within the reach of the population29.

The treatment of breast cancer in elderly women is harmed by innumerable mistakes, often resulting in sub-treatment, due to a belief that they are more fragile to the existing treatments, and that their co-morbidities will have a direct influence on the outcome9,29. It is observed in this present study that the majority of the elderly women were treated with all the therapeutic modalities available in the service, such as: surgery, chemotherapy, radiotherapy and hormone therapy. It can be seen that these subjects were evaluated for a series of variables, including age, stage of the disease, absence or presence of metastases, the power of toxicity of the medications, and their cost-benefit relationship. As to the therapeutic strategies, formulation of a single protocol for treatment is still distant, and the most coherent approach is discussion case by case in the context of a multidisciplinary team49.

The Brazilian Society of Mastology49 argues that omission of radiotherapy, although it does not interfere in the survival time of the patient, increases the risk of occurrence of local relapse, but that the benefit of this treatment may be less for elderly women, since they are a population with low risk of this type of relapse. Some authors31 state that the size of the tumor is directly linked to the risk of relapse, and is a predictive factor. Relapse was uncommon, presenting similar results to those found in the existing literature40,42.

The principal characteristic of cancer is the capacity to metastasize. The genetics of the tumor are an important factor in metastatic disease; it is believed that the information for development of the metastases is already contained on the DNA of the tumor as from its emergence50.

Elderly women have a lower chance of developing metastases than younger women49,51. The percentage of this event varies between the studies37,38,40, but it is clear that it is the principal cause of deaths from cancer52. As in the present study, the literature points to lungs and bones as frequent locations for occurrence of metastases38,39.

Even before Law 12732 was enacted, the average time from diagnosis to start of treatment of the women studied was satisfactory – its institution, years later, showed a desire for speed and commitment in public health. Authors15,53argue that the most delayed factor is achievement of a diagnosis – the time between the first consultation and the diagnosis – which is not the case in the present study. The total time between seeking out the health service, diagnosis and start of treatment indicates a capacity for solution, and was lower than in studies carried out in other health services15,53.

It is shown that older women were attended more rapidly; this result is in harmony with the study carried out in women over age 65 in the United States54. In the United Kingdom55, on the other hand, women above this age group showed higher intervals of time between diagnosis and start of treatment.

At two health services in Florianópolis (Brazil), arrival at the service with a diagnosis and prior treatment conferred longer survival to women, while arrival without a diagnosis and without treatment doubled the risk of death56. In the present study, receiving the diagnosis and all of the treatment in the service studied achieved longer times. Considering that the time elapsed between the diagnosis and the start of treatment is an important variable and that it influences the prognosis of the patient12, possibly, arriving at the service without a diagnosis and with no prior treatment improves the patient’s prognosis, and can mean a longer survival time.

Since breast cancer has a much better prognosis when found at early stages37,39,41,56, there has been a tendency to give priority to women with a higher chance of cure and/or survival time. The speed of the treatment in women with early stage disease and more delayed treatment in those with more advanced disease is seen in various other studies15,57-59. On the other hand, in a study in Espírito Santo State12, the trend was to prioritize the most serious cases, treating women with Stage III and IV more rapidly.

It is important to emphasize that the populations studied have different characteristics, since the study referred to was carried out with women of all the age groups, and the present study involved only women over age 60. This could have affected the order of priority of attendance, since younger women (as from the third decade of life) have better prognoses than elderly women31,49and starting treatment more rapidly is a determining factor for increase of chances of cure/survival time41. Older women usually have associated co-morbidities, fragilities arising from age, less life expectancy, interfering in the choice9,29,60,61and in the speed of the treatment, often erroneously, due to unfounded beliefs49,60,61, since aging is a multi-dimensional and totally individualized process and one that does not necessarily obey a pattern of physiological decline29.

There are divergences in the literature as to the intervals between diagnosis and treatment and the consequences for patients12,15,60,62. Studies affirm that delay in the diagnosis does not harm the prognosis12,60,62and the survival time of the patient12,62. Others, on the other hand, conclude that this interval does have a negative impact on the patient18-21. In the present study it was observed that time does affect the outcome, and that faster care offers better conditions for treatment of the disease, with more satisfactory results. Early diagnosis and treatment of breast cancer are important factors in reduction of mortality21,43. Strategies such as monitoring for early detection are of fundamental importance and underline the importance of the race against time22,43.

Authors consider that the earlier that treatment begins for initial tumors, the greater are the chances of cure15. Delay in diagnosis is related to later stages of the disease63 and higher risks of metastasis20. Occurrence of metastasis and relapse is directly related to reduction of survival time and worse prognosis12,21.

The non-completeness of some variables, and the imprecision of the data record, with possible loss of information due to incomplete filling in of medical records64, were limitations of this study. The involvement of managers, health professionals and record keepers of the RHCs is vitally essential for achieving completeness and precision of data so as to improve the quality of the information65.

Conclusion

Receiving of diagnosis, and all of the treatment, within the service that was the subject of this study, guaranteed better times. It is emphasized that the period studied preceded the ‘60-day Law’, and that even so the intervals of time found showed quality and resolvability in the service provided.

This study, carried out with secondary data, was of extreme importance for improving knowledge on the time from diagnosis to start of treatment in elderly women with breast cancer. It serves as a basis for planning of strategies in clinical and policy intervention for the provision of care to elderly women by interdisciplinary teams.

Acknowledgements

We wish to acknowledge the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) and the Centro de Referência da Saúde da Mulher (Women’s Health Reference Center) at the Pérola Byington Hospital.

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Received: March 09, 2015; Revised: June 16, 2015; Accepted: June 18, 2015

Collaborations

CB Souza, SM Fustinoni, MH Amorim, E Zandonade, JC Matos and J Schirmer participated in the conception, design, analysis and interpretation of data; in the write-up of the article and relevant critical revision of intellectual content; and in final approval of the version for publication. They are responsible for all aspects of the study, and guaranteeing the accuracy and integrity of all elements of the research.

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