Differences in breast cancer diagnosis by patient presentation in Ontario: a retrospective cohort study

Abstract

Background: In Ontario, patients with breast cancer typically receive their diagnoses through the Ontario Breast Screening Program (OBSP) after an abnormal screen, through screening initiated by a primary care provider or other referring physician, or through follow-up of symptoms by patients' primary care providers. We sought to explore the association of the route to diagnosis (screening within or outside the OBSP or via symptomatic presentation) with use of OBSP-affiliated breast assessment sites (O-BAS), wait times until diagnosis or treatment, health care use and overall survival for patients with breast cancer.

Methods: In this retrospective cohort study, we used the Ontario Cancer Registry to identify adults (aged 18-105 yr) who received a diagnosis of breast cancer from 2013 to 2017. We excluded patients if they were not Ontario residents or had missing age or sex, or who died before diagnosis. We used logistic regression to evaluate factors associated with categorical variables (whether patients were or were not referred to an OBAS, whether patients were screened or symptomatic) and Cox proportional hazards regression to identify factors associated with all-cause mortality.

Results: Of 51 460 patients with breast cancer, 42 598 (83%) received their diagnoses at an O-BAS. Patients whose cancer was first detected through the OBSP were more likely than symptomatic patients to be given a diagnosis at an O-BAS (adjusted odds ratio 1.68, 95% confidence interval [CI] 1.57 to 1.80). Patients screened by the OBSP were given their diagnoses 1 month earlier than symptomatic patients, but diagnosis at an O-BAS did not affect the time until either diagnosis or treatment. Patients referred to an O-BAS had significantly better overall survival than those who were not referred (adjusted hazard ratio 0.73, 95% CI 0.66 to 0.80).

Interpretation: Patients screened through the OBSP were given their diagnoses earlier than symptomatic patients and were more likely to be referred to an O-BAS, which was associated with better survival. Our findings suggest that individuals with signs and symptoms of breast cancer would benefit from similar referral processes, oversight and standards to those used by the OBSP.

Figure 1:

Categorization of patients as screened through the Ontario Breast Screening Program (OBSP-screened), screened outside the OBSP (non-OBSP-screened) or symptomatic. Note: ICMS = Integrated Client Management System, OHIP = Ontario Health Insurance Plan.

Figure 2:

(A) The proportion of all patients with breast cancer whose cancer was detected by screening at an Ontario Breast Screening Program (OBSP-screened), by screening outside an OBSP (non-OBSP-screened) or by symptoms. (B) The proportion of patients with breast cancer presumed to be eligible for OBSP (female patients aged 50–74 yr, no previous breast cancer) whose cancer was detected by screening at an OBSP, by screening outside an OBSP or by symptoms.

Figure 3:

Kaplan–Meier plot for overall survival (by whether the patient’s breast cancer was detected by the Ontario Breast Screening Program (OBSP-screened), by screening outside of the OBSP (non-OBSP-screened) or by symptoms and by whether they were referred to an OBSP-affiliated breast assessment site (O-BAS) for diagnosis. We corrected time from diagnosis for lead-time bias.