The Association of Care Fragmentation on Overall Survival for Early Stage Breast Cancer.

Abstract

Introduction: Optimal treatment of stage I-III breast cancer requires multimodal therapies. Patients can receive these therapies at one or multiple facilities. Herein, we evaluated the association of receiving treatment at more than one facility and distance to that facility on overall survival.

Methods: The 2004-2019 National Cancer Database was queried for patients with stage I-III breast cancer who received at least two modalities of treatment. "Coordinated care" was designated when a patient received all modalities of treatment at the same facility and "fragmented care" was designated when a patient received treatment at two or more facilities. Multivariable logistic regression was performed to identify factors associated with fragmented care. Overall survival was compared using Kaplan-Meier and Cox proportional hazards methods.

Results: A total of 536,896 patients met the study criteria, of which 317,038 (59.1%) patients received coordinated care and 219,848 (40.9%) patients received fragmented care. Decreased mortality was seen with fragmented care in stage II and III patients (hazard ratio (HR): 0.92 and 0.94 respectively; 95% confidence interval (CI): 0.88-0.97, 0.89-0.99; P < 0.001), and receipt of care at an Academic/Research Program (HR: 0.89; 95% CI: 0.84-0.93). Unexpectedly, living greater than 50 miles away from the treating facility was also associated with decreased mortality (HR: 0.85; 95% CI: 0.81-0.90]), although this represented a small minority of patients (N = 30,290, 6.5%).

Conclusions: For patients with early-stage breast cancer, receipt of fragmented care and greater distance to treating facility were not associated with worse outcomes. These results support patients' receipt of some care locally, underscoring the need for effective communication across the clinical care team.