ABSTRACT
BACKGROUND: For patients with breast cancer who decline recommended treatments, available data examining survival outcomes are sparse. We compared overall survival and relapse-free survival outcomes between patients with breast cancer who declined recommended primary treatments and those who received recommended primary treatments. METHODS: Using data from the BreastSurgANZ Quality Audit database, a retrospective cohort study was performed for patients diagnosed with breast carcinoma (stage 0-IV) between 2001 and 2014 who were treated in our integrated cancer centre. A propensity score-matched analysis was performed to compare overall survival and relapse-free survival between patients who either declined or received the standard recommended treatment. RESULTS: A total of 56/912 (6.1%) patients declined one or more recommended therapies. Five-year overall survival for those who declined or received treatment as recommended was 81.8% versus 88.9% (P = 0.17), respectively. Ten-year survival was 61.3% versus 67.8% (P = 0.22), respectively. For patients who declined treatments, 5-year relapse-free survival was 72.4%, compared to 87.4% for those who received them (P = 0.005). Ten-year relapse-free survival was 61.0% versus 80.6% (P = 0.002), respectively. On adjusted Cox regression analysis, treatment refusal was associated with poorer relapse-free survival (adjusted hazard ratio 2.76 (95% confidence interval 1.52-5.00), P < 0.001). CONCLUSION: In conclusion, patients who declined recommended treatment for breast cancer had poorer relapse-free survival compared to those who received them. These data may help clinicians assist patients with breast cancer in their decision-making.
Subject(s)
Breast Neoplasms , Breast Neoplasms/therapy , Female , Humans , Neoplasm Recurrence, Local/epidemiology , Propensity Score , Proportional Hazards Models , Retrospective Studies , Survival AnalysisABSTRACT
BACKGROUND: Prehospital triage of ST-elevation myocardial infarction (STEMI) for primary percutaneous coronary intervention (PCI) reduces treatment times. Prehospital triage and transport of STEMI patients have traditionally been undertaken in emergency medical service systems with Advanced Care Paramedics (ACPs). However, ACPs are not available in many regions. A pilot study was conducted to determine the feasibility of prehospital STEMI triage in a region with only Primary Care Paramedics. METHODS: Hemodynamically stable patients with chest pain and suspected STEMI were brought directly to a catheterization laboratory for primary PCI. End points included accuracy of prehospital STEMI identification, complications during transfer, and treatment times. RESULTS: One hundred thirty-four consecutive patients with suspected STEMI were triaged for primary PCI. Only 1 patient developed complications during transport (rapid atrial flutter) that required ACP skills. One hundred thirty-three patients underwent urgent angiography, and 105 patients underwent PCI. Based on physician interpretation of the prehospital electrocardiogram, there was agreement with triage decision for 121 (90%) of the 134 cases. The final diagnosis based on the angiogram and cardiac markers was true STEMI for 106 patients and false positive for 28 patients. The median first medical contact to balloon time was 91 (81-115) minutes. CONCLUSIONS: Hemodynamically stable patients with suspected STEMI can be safely and effectively transported directly for primary PCI by paramedics without advanced care training. Prehospital STEMI triage for primary PCI can be extended to regions that have few or no paramedics with advanced care training.
