Invest in Human Capital to Improve Breast Cancer Care Delays: Adam Brufsky, MD, PhD

Some of the many delays patients encounter from receiving a breast cancer diagnosis to starting on their treatment journey run the gamut from scheduling appointments for biopsy and surgical consults to their clinician booking an operating room (OR). In this interview from the recent Institute for Value-Based Medicine® event held in Pittsburgh, Adam Brufsky, MD, PhD, highlights these and other obstacles to more timely treatment, as well as underscores the importance of increasing investment in adequate human capital.

Brufsky is professor of medicine; associate chief of the Division of Hematology/Oncology; and codirector of the Comprehensive Breast Cancer Center at the University of Pittsburgh. He moderated the discussion, “Gaps and Unmet Needs in the Journey of Patients With Breast Cancer.”

This transcript has been lightly edited for clarity; captions were auto-generated.

Transcript

What are main contributors to delays between breast cancer diagnosis and treatment, and what practical steps can health systems take to shorten these intervals?

There are many. I think a lot has to do with just scheduling appointments. For example, just getting an appointment for a biopsy. If you have an abnormality, say on a mammogram or an ultrasound, getting an ultrasound-guided biopsy could be quite difficult in some places just because of volume concerns. There may not be enough people or enough machines. A big one is MRI. Now that MRI has become a little bit more common based on the ASCO/ACS [American Society of Clinical Oncology/American Cancer Society] guidelines, getting a screening MRI has been very difficult. I have patients who take 6 to 9 months to be able to get an MRI, a breast MRI, in the Pittsburgh area. It really is crazy. That's one thing, just getting the biopsy.

Then, once you get the biopsy, it's getting an appointment with a surgeon, because again, many surgeons are very busy, and it's very difficult to really get an appointment with a breast surgeon for several weeks after you even have the biopsy. Then once you get it, the workup can be more complicated. That's another reason for delay. For example, it turns out that some women want to do chemotherapy before surgery, want to do neoadjuvant chemotherapy, and as a result, it may take several days to get in to see a medical oncologist, and then they have to get all the testing done to kind of get ready, maybe an echocardiogram if they're getting any anthracycline or an MRI to kind of see the extent of disease in their breast, if they're going to do that, or maybe even staging scans, like a CT scan or a PET scan. That takes time, so you have all of that.

Then on top of that, even if they don't get neoadjuvant chemotherapy, there's OR time. Scheduling an OR, and especially if someone wants to have a prophylactic mastectomy with a reconstruction, that takes a long time. That often takes 6 to 8 to 10 weeks.

What can systems do to change that? Well, first of all, one thing that I think the American College of Surgeons is doing now and has been doing for a long time, as well as other rating agencies and accreditation agencies, is actually looking at your timing. You actually have to list in your breast center how long it takes to get from getting a diagnosis and then from diagnosis to a surgeon, then from a surgeon to the medical oncologist and from the medical oncologist and surgery to radiation therapy. You are rated on that and judged on that; you have to have certain percentages. That's one thing systems are forced to do.

But I really think that probably the biggest thing systems really could do is take a good, hard look at their breast center and at their breast programs, at their cancer programs in general, and try to understand where those pressure points are and devote resources to those areas. It's nice to have a beautiful, gorgeous breast center, with beautiful new marble and mirrors and statues or whatever, but on the other hand, what really makes a good breast center is not the way it looks, but it's how it functions, and I think spending time on human capital is probably the most important thing that systems can do in this area.