# Root Cause Analysis of Omissions and Delays in the Initiation of Neoadjuvant Chemotherapy in Eligible Patients with Breast Cancer in British Columbia, Canada

## TL;DR

This study identifies delays in starting neoadjuvant chemotherapy for breast cancer patients in Canada, finding that late referrals to medical oncology are a major cause.

## Contribution

The study provides a root cause analysis of NACT omissions and delays, highlighting the role of medical oncology triage.

## Key findings

- Only 21% of eligible patients started neoadjuvant chemotherapy within 28 days of diagnosis.
- Delays in medical oncology consultation were the main cause of NACT delays.
- Improving triage to medical oncology could enhance treatment outcomes for eligible patients.

## Abstract

Neoadjuvant chemotherapy (NACT) can reduce the extent of surgery and improve outcomes for patients with high-risk breast cancers. Chemotherapy should be started shortly after diagnosis to be most effective. However, steps between diagnosis and starting NACT can prevent patients from receiving treatment and impose delays. In this study, we aimed to find reasons leading to omission or delays in receiving NACT in eligible patients. Seventy-three percent (73/100) of eligible patients received neoadjuvant chemotherapy. However, of these patients, only 21% (15/73) started chemotherapy within 28 days of diagnosis, with patients waiting a median of 40 days [IQR 30–53] from diagnosis to starting NACT. Referral to medical oncology was identified as the key obstacle to neoadjuvant chemotherapy receipt. Improving triage to medical oncology for patients eligible for NACT could improve their outcomes.

Patients with high-risk breast cancers may benefit from receiving neoadjuvant chemotherapy (NACT) to reduce tumour size and allow for breast conserving surgery. Response to NACT also informs prognosis and broadens adjuvant treatment options. According to international guidelines, NACT should commence within 28 days of diagnosis. We conducted a retrospective chart review of patients eligible for NACT at a Canadian provincial cancer centre to determine the incidence and root causes of omission or delay in initiation of NACT. Of 100 patients eligible for NACT, 73 received it, while 7 were not referred to medical oncology for consideration of NACT. Of the 73 patients who received NACT, only 15 (21%) started treatment within 28 days of diagnosis. The median diagnosis-to-NACT wait time was 40 days [IQR 30–53]. Of 54 delayed cases, 39 (72%) were due to patients waiting 21 days or more for a medical oncology consultation. Lack of, or delays in medical oncology consultation are the most prominent causes of both NACT omissions and delays. Improving triage of patients potentially eligible for NACT to medical oncology may be an effective intervention to improve patient outcomes.