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Background: Access to medical care vary across the world and is related to different health systems with an impact in recurrence.Objective: To evaluate disparities in breast cancer(BC) diagnosis and treatment between public and private services in southwest Brazil and at two public safety net hospitals in Houston, Texas.Methods: Women diagnosed with BC stages I-III between 2009 to 2011, and treated at the four hospitals in Brazil and two health centers in US were included. All statistical analyses were performed in R studio software, and p<0.05 was considered significant.Results: 1245 women were included: 967 from public health system (PHS) (20.3% from Houston, Texas) and 274 from private system(PS). Recurrence rate was higher in PHS (14.6% vs. 2.6%, p<0.001) Table 1. Clinical and demographic characteristics of the patientsCharacteristicsPublic (%), n=967Private (%), n=274pDiscovery of BC   By patient530 (54.8)92 (33.5) Routine exam87 (9)109 (39.8) Screening mammography270 (27.9)23 (8.4) Other80 (8.3)50 (18.3)<0.001Initial treatment   Surgery687 (71)241 (88) Neo-adjuvant chemotherapy224 (23.2)27 (9.8) Neo-adjuvant hormone therapy23 (2.3)27 (9.8) Not available33 (3.4)3 (1.1)<0.001Clinical Stage   I293 (30.3)113 (41.2) II342 (35.4)52 (19) III271 (28)15 (5.5) Unknown61 (6.3)94 (34.3)<0.001Subtype   HR+/HER2 -561 (58)192 (70.1) HR-/HER2+108 (11.1)29 (10.6) HR-/HER2+76 (7.9)14 (5.1) Triple negative149 (15.4)28 (10.2) Unknown73 (7.6)11 (4)0.012Symptomatic at Diagnosis   Yes591 (61.1)100 (36.5) No306 (31.6)97 (35.4) Unknown70 (7.2)77 (28.1)<0.001Recurencen=772n=146 No719 (74.4)193 (70.4) Yes142 (14.6)7 (2.6) Unknown106 (11)74 (27)<0.001 . Considering the interval in weeks: symptoms to diagnosis, diagnosis to first treatment (either surgery or neoadjuvant chemotherapy), diagnosis to first systemic treatment, diagnosis to surgical treatment and diagnosis to radiotherapy were longer in public patients (24.1 vs. 8.7; 11.1 vs. 3.5; 18.6 vs. 9.8; 16.9 vs. 5.6; 51.4 vs. 26.1; p<0.001). Table 2. Delay disparities between public and private health system PublicPrivatepSymptoms to diagnosis   Number of patients575146 Time (weeks)24.1 (0.4-104.9)8.7 (0.0-43.7)<0.001Diagnosis to first treatment   Number of patients663180 Time (weeks)11.1 (2.0-31.5)3.5 (0.0-11.0)<0.001Diagnosis to first systemic treatment   Number of patients526106 Time (weeks)18.6 (2.6-44.7)9.8 (1.9-29.3)<0.001Diagnosis to surgical treatment   Number of patients657178 Time (weeks)16.9 (3.4-45.6)5.6 (0.0-32.9)<0.001Diagnosis to radiotherapy   Number of patients465127 Time (weeks)51.4 (18.7-88.4)26.1 (5.6-66.4)<0.001 In multivariate analysis, PHS (HR 1.72; 95% CI 1.34-1.88; p adj=0.003), presence of symptoms (HR 2.29; 95% CI 1.39-3.78; p adj=0.001), clinical stage III (HR 1.62; 95% CI 1.35-1.93; p adj<0.001), and triple negativity and HER2neu positivity (1.18; 95% CI 1.03-1.35; p adj=0.021) were all associated with a higher recurrence rate.Conclusions: There were significant disparities between PHS and PS. Women in the PHS presented higher rates of recurrence, advanced clinical stages at diagnosis, symptoms and more aggressive subtypes by IHC. additionally, the interval between symptoms to diagnosis and diagnosis to treatments was longer in PHS. Citation Format: NematiShafaee M, Natal RA, Ramalho S, Dória MT, Conz L, Cabello V, Pavanello M, Mano MS, Linck RDM, Batista LS, Pedro EP, Bines J, de Paula BH, Zucca-Matthes G, Bondy ML, Ellis MJ, Podany E, Debord L, Makawita S, Stewart K, Cabello C. Impact of delay in breast cancer diagnosis and treatment according to health insurance status in southwest Brazil and Houston, Texas [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-10-15.

Background: Delays in diagnosis and treatment is associated with recurrence. Access to medical care in public health systems (PHS) may vary across Southwest Brazil and Houston, Texas. Objective: To evaluate disparities in breast cancer (BC) diagnosis and treatment between public services in southwest Brazil and at a public safety net hospital in Houston, Texas. Methods: Women diagnosed with BC stages I-III between 2009 to 2011, and treated at thefour hospitals in Brazil and two health centers in US were included. All statistical analyses was performed in R studio, and p<0.05 was considered significant. Results: 967 women from PHS were included: 778 from Brazil and 189 from US. Recurrence rates were not significantly different (15.9% vs. 9.5%, p=0.233) Table 1. Clinical and demographic characteristics of the patientsCharacteristicsBrazil (%), n=778US (%), n=189pDiscovery of BC   By patient443 (56.9)87 (46) Routine exam82 (10.5)5 (2.7) Screening mammography207 (26.6)63 (33.4) Other46 (6)34 (17.9)<0.001Initial treatment   Surgery587 (75.4)100 (52.9) Neo-adjuvant chemotherapy176 (22.6)48 (25.4) Neo-adjuvant hormone therapy9 (1.1)14 (7.4) Unknown6 (0.9)27 (14.3)<0.001Clinical Stage   I234 (30.1)59 (31.2) II289 (36.8)56 (29.7) III239 (30.7)32 (16.9) Unknown19 (2.4)42 (22.2)0.027IHQ Subtype   HR+/HER2 -467 (60)94 (49.7) HR+/HER2+91 (11.7)17 (9) HR-/HER2+66 (8.5)10 (5.3) Triple negative123 (15.8)26 (13.8) Unknown31 (4)42 (22.2)0.853Symptoms   Yes492 (63.2)99 (52.4) No248 (31.9)58 (30.7) Unknown38 (4.9)32 (16.9)0.410Recurence   No599 (77)120 (63.5) Yes124 (15.9)18 (9.5) Unknown55 (7.1)51 (27.0)0.233 . Considering the interval in weeks: symptoms to diagnosis, diagnosis to first systemic therapy and diagnosis to radiotherapy were longer in Brazil PHS patients (24.4 vs. 22.8; 18.9 vs. 16.1 and 51.8 vs. 47.8 p<0.001). Table 2. Delay disparities in public health system between Brazil and US BrazilUSpSymptoms to diagnosis   Number of patients473102 Time (weeks)24.4 (0.5-102.6)22.8 (0.1-124.8)<0.001Diagnosis to first treatment   Number of patients546117 Time (weeks)10.8 (1.9-31.7)12.2 (3.1-26.4)<0.001Diagnosis to first systemic treatment   Number of patients45967 Time (weeks)18.9 (2.4-45.6)16.1 (3.3-38.6)<0.001Diagnosis to surgical treatment   Number of patients541116 Time (weeks)16.4 (3.1-43.1)19.2 (4.5-51.2)<0.001Diagnosis to radiotherapy   Number of patients41352 Time (weeks)51.8 (19.4-89.7)47.8 (14.9-84.8)<0.001 However, considering the interval in weeks: diagnosis to first treatment (either surgery or neoadjuvant chemotherapy) and diagnosis to surgical treatment were shorter in Brazil PHS patients (10.8 vs. 12.2 and 16.4 vs. 19.2, p<0.001). When considering surgery as initial treatment, treatment in Brazil PHS and stage III disease at diagnosis were associated with worse prognosis (HR: 1.91, 95%CI: 1.38 – 1.99, padj=0.015; HR 1.44, 95%CI:1.11-1.87, padj=0.006). Conclusions: There were significant disparities between Brazil and US PHS. Women in Brazil PHS presented higher rates of advanced clinical stages at diagnosis and diagnosis by routine exam, while US PHS present higher rates of diagnosis by screening mammography. When considering surgery as initial treatment, Houston PHS women had a better prognosis. Citation Format: Ramalho S, Dória MT, Natal RA, Conz L, Cabello V, Pavanello M, Cabello C, Mano MS, Linck RD, Batista LS, Pedro EP, Bines J, de Paula BH, Zucca-Matthes G, Ellis MJ, Podany E, Debord L, Makawita S, Stewart K, NematiShafaee M, Bondy ML. Impact of delay in breast cancer diagnosis and treatment in public health according to nationality: Brazil vs US [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-10-16.