Background. Although treatment delays have been associated with survival impairment for invasive breast cancer, this has not been thoroughly investigated for ductal carcinoma in situ (DCIS). With trials underway to assess whether DCIS can remain unresected, this study was performed to determine whether longer times to surgery are associated with survival impairment or increased invasion. Methods. A population-based study of prospectively collected national data derived from women with a clinical diagnosis of DCIS between 2004 and 2014 was conducted using the National Cancer Database. Overall survival (OS) and presence of invasion were assessed as functions of time by evaluating five intervals (B 30, 31-60, 61-90, 91-120, 121-365 days) between diagnosis and surgery. Subset analyses assessed those having pathologic DCIS versus invasive cancer on final pathology. Results. Among 140,615 clinical DCIS patients, 123,947 had pathologic diagnosis of DCIS and 16,668 had invasive ductal carcinoma. For all patients, 5-year OS was 95.8% and unadjusted median delay from diagnosis to surgery was 38 days. With each delay interval increase, added relative risk of death was 7.4% (HR 1.07; 95% CI 1.05-1.10; P \ 0.001). On final pathology, 5-year OS for noninvasive patients was 96.0% (95% CI 95.9-96.1%) versus 94.9% (95% CI 94.6-95.3%) for invasive patients. Increasing delay to surgery was an independent predictor of invasion (OR 1.13; 95% CI 1.11-1.15; P \ 0.001). Conclusions. Despite excellent OS for invasive and noninvasive cohorts, invasion was seen more frequently as delay increased. This suggests that DCIS trials evaluating nonoperative management, which represents infinite delay, require long term follow up to ensure outcomes are not compromised. Ductal carcinoma in situ (DCIS) is a premalignant lesion composed of malignant mammary ductal epithelial cells that have not yet invaded the basement membrane, whose standard interventions have included lumpectomy and radiotherapy or total mastectomy alone, followed by endocrine therapy. 1-5 Defined as American Joint Commission of Cancer (AJCC) Stage 0, patient outcomes following standard treatment are excellent, with 5-year survival typically [ 95%. 2,6-8 Recently, therapies for DCIS have been scrutinized, as current data suggest that \ 50% of afflicted patients will develop invasive cancer without treatment. 1,2,8 Additionally, although DCIS detection has increased over recent decades secondary to mammographic improvements, advanced stage distributions have not correspondingly declined, suggesting that screening may detect some DCIS that would remain subclinical. 2,4,9-13 Many have Dr. Ward is a military service member. This work was prepared as part of his official duties. The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government.

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Purpose Breast conservation therapy (BCT) is standard for T1-T2 tumors, but early trials excluded breast cancers >5 cm. This study was performed to assess patterns and outcomes of BCT for T3 tumors. Methods We reviewed the National Cancer Database (NCDB) for noninflammatory breast cancers >5 cm, between 2004–2011 who underwent BCT or mastectomy (Mtx) with nodal evaluation. Patients with skin or chest wall involvement were excluded. Patients having clinical T3 tumors were analyzed to determine outcomes based upon presentation, with those having pathologic T3 tumors, subsequently assessed, irrespective of presentation. Overall survival (OS) was analyzed using multivariable Cox proportional hazards models, with adjusted survival curves estimated using inverse probability weighting. Results After exclusions, 37,268 patients remained. Median age and tumor size for BCT vs Mtx was 53 vs 54 years (p<0.001), and 6.0 vs 6.7 cm (p<0.001), respectively. Predictors of BCT included age, race, location, facility type, year of diagnosis, tumor size, grade, histology, nodes examined and positive, and administration of chemotherapy and radiotherapy. OS was similar between Mtx and BCT (p=0.36). This held true when neoadjuvant chemotherapy patients were excluded (p=0.39). BCT percentages declined over time (p<0.001) while tumor sizes remained the same (p=0.77). Median follow up was 51.4 months. Conclusions OS for patients with T3 breast cancers is similar whether patients received Mtx or BCT, confirming that tumor size should not be an absolute BCT exclusion. Declining use of BCT for tumors >5 cm in younger patients may be accounted for by recent trends towards mastectomy.

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Purpose Breast cancer outcomes are impaired by both delays and disparities in treatment. This study was performed to assess their relationship and to provide a tool to predict patient socioeconomic factors associated with risk for delay. Methods The National Cancer Database was reviewed between 2004 and 2017 for patients with non-metastatic breast cancer managed with upfront surgery. Times to treatment were measured from the date of diagnosis. Patient, tumor, and treatment factors were assessed with attention paid to sociodemographic variables. Results 514,187 patients remained after exclusions, with 84.3% White, 10.8% Black, 3.7% Asian, and Hispanics comprising 5.6% of the cohort. Medicaid and uninsured patients had longer mean adjusted time to surgery (≥ 46 days) versus private (36.7 days), Medicare (35.9 days), or other governmental insurance (39.8 days). After adjustment, Black race and Hispanic ethnicity were most impactful, adding 6.0 and 6.4 preoperative days, 10.9 and 11.5 days to chemotherapy, 11.1 and 9.1 days to radiation, and 12.5 and 8.9 days to endocrine therapy, respectively. Income, education, and insurance, among other factors, also affected delay. A nomogram, including race and sociodemographic factors, was created to predict the risk of preoperative delay. Conclusion Significant disparities exist in timeliness of care for factors, including but not limited to, race and ethnicity. Although exact causes cannot be discerned, these data indicate population subsets whose intervals of care risk being longer than those specified by national quality standards. The nomogram created here may help direct resources to those at highest risk of incurring a treatment delay. Supplementary Information The online version contains supplementary material available at 10.1007/s10549-021-06460-9.