Many people question how long they can wait to begin treatment for breast cancer. For any number of reasons, you may wonder whether surgery for breast cancer needs to happen next week, if chemotherapy after surgery (adjuvant chemotherapy) can be delayed for a month or two, or if treatment for stage 4 cancers needs to begin immediately.
While some experts recommend that, on average, people should wait less than 90 days for surgery, other studies suggest that young women or people with certain subtypes of tumors should plan to have surgery much sooner. The same appears to be true with chemotherapy, where there appear to be benefits to starting within 30 days, especially for those who have tumors that are HER2 positive, triple negative, or have positive lymph nodes.
In order to make an empowered decision in your own care, let’s look at what research is telling us about the effect of treatment delays on survival with respect to several characteristics of breast cancers that may be unique to you.
Although we are discussing treatment delays, let’s begin with a few reasons why waiting a few days or weeks may be beneficial.
Reasons to Wait a Short While
While much of the research suggests having surgery within a few weeks and chemotherapy within a month is ideal, there are some very good reasons why you may wish to wait a few days or a few weeks to begin treatment.
Most surgeons and oncologists will reassure you that you have some time, though there are always exceptions to that general rule (for example, if you have a tumor pressing on a vital organ). Advantages of taking some time include:
- Time to learn about your diagnosis and choose the best surgeon. Just like some plumbers or home painters do a better job than others, doctors are human and vary in their expertise.
- Time to learn about your surgical options. There are many choices to make, not just between a lumpectomy and mastectomy. If you will have a mastectomy, will you want immediate or delayed reconstruction? Newer procedures such as nipple-sparing/skin-sparing mastectomies are a great option for some women, but not all surgeons do these procedures.
- For young women with breast cancer, time to see a fertility specialist to talk about fertility preservation. Chemotherapy often leads to infertility, but there are measures you can take beforehand if you wish to have a child after treatment.
- Time to get a second opinion. Getting a second opinion is almost always a good idea. Not only do doctors have different levels of experience and interest, but having a second opinion can be reassuring if you ever look back and question your choices.
- Make sure any medical conditions you have are under good control. If you have any medical conditions such as diabetes or high blood pressure, taking a short while to make sure your blood sugars or blood pressures are stable can be wise.
- Time to quit smoking if you smoke. Quitting smoking before surgery—even if only a few days beforehand—lowers the risk of complications.
- Time to prepare for after treatment. You will need time to heal after surgery and time to rest after any treatment. Taking a few days or even a few weeks can give you time to arrange childcare, set up a schedule for people to bring meals, and more. Setting up a site such as Lotsa Helping Hands can help you coordinate your helpers without dozens of calls. Many people also set up an account at a site such as Caring Bridge (or have a loved one do so) through which they can keep people updated on their progress.
- Time to have a preoperative MRI on the same breast as your breast cancer (if you are planning on a lumpectomy) and/or on your other breast.
- Time to make sure you can coordinate schedules between your surgeon and plastic surgeon if you plan on immediate reconstruction.
- Finally, taking a few days gives you time to shop around could potentially save you a lot of money.
Optimal Wait Time Before Surgery
We lead busy lives. Some people wonder if they can wait until an upcoming vacation to have surgery, or until their children are back in school. Others hope to wait until their insurance kicks in at a new job, or until they are able to find insurance. And not everyone feels quite ready to have surgery right after being diagnosed.
The average wait time until surgery has actually been increasing, with the average delay being 21 days in 1998, 31 days in 2003, and 41 days in 2008.
How long can you wait? Let’s look at studies of overall survival as well as special groups.
Studies on Time to Surgery and Survival
Several studies have been done, but there are some differences in how these were conducted that can affect the results. For example, some studies have looked at the time between a definitive diagnosis and surgery, and others have looked at the time between the onset of symptoms (such as a lump) and the time of surgery. Some have looked at averages of all people, whereas others have separated out people based on age, tumor type, and receptor status. Studies can also be skewed, as doctors may recommend surgery sooner for women who have more aggressive tumors. Let’s look at time to surgery and survival rates in different groups of people.
Survival and Time to Surgery (All Ages)
A 2016 study published in JAMA Oncology looked at data from over 115,000 people (between 2003 and 2005) via the National Cancer Database (NCDB). This study included people age 18 and older who were cared for at Commission on Cancer-accredited cancer centers across the United States.
All of the people had early stage (non-metastatic) breast cancer with surgery as their first treatment. They then looked at wait times to surgery and survival rates at five different intervals: a wait of less than 30 days, a wait time of 31 to 60 days, a wait time of 61 to 90 days, a wait time of 91 to 120 days, and a wait time of 121 to 180 days.
They found that for each 30-day interval of delay, survival rates decreased for people with stage I and stage II breast cancer. The conclusion was that although time is needed to discuss treatment options and prepare, earlier surgery is better.
The same study as above also looked at close to 100,000 people aged 65 and older (between 1992 and 2009) in the Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database. Looking at the same intervals, each interval of delay was also associated with lower overall survival for those with stage I and stage II breast cancer, with lower disease-specific survival rates with each 60 day interval. The conclusion was the same as above—earlier surgery (ideally within 30 days) is better.
For women who are young (defined as 15 to 39), a 2013 study in JAMA Surgery suggested that young women should have surgery no more than six weeks after diagnosis and preferably earlier. This study of close to 9,000 women found 5-year survival rates as follows:
- 84 percent among those who had surgery within two weeks
- 83 percent among those who had surgery two to four weeks after diagnosis
- 78 percent among those who had surgery more than six weeks after diagnosis
A delay in surgery affected survival to a greater degree in black and Hispanic people than in non-Hispanic whites.
Delay in Surgery and Tumor Growth: HER2 and Triple Negative Tumors
The optimal time between diagnosis and surgery can also be looked at from the standpoint of tumor growth, although the doubling rate (how long a breast cancer takes to double in size) varies between different tumors.
A 2016 study, though it didn’t look at survival, did evaluate the growth rate of breast cancers during wait time for surgery by ultrasound measurements. In this study, the average wait time between diagnosis and surgery was 31 days (with a range of 8 to 78 days).
The average diameter and volume of tumors at diagnosis was 14.7 millimeters and 1.3 centimeters vs. 15.6 millimeters and 1.6 centimeters.
The growth rate of different tumors based on receptor status, however, was very different:
- Triple-negative tumors: 1.003 percent growth each day
- HER2 positive tumors: 0.850 percent growth each day
- Luminal B/A tumors (estrogen receptor positive tumors): 0.208/0.175 percent growth each day
As noted, tumors that were triple negative or HER2 positive grew much faster. This was also linked to an increase in stage based on size between diagnosis and surgery, with 18 percent of triple-negative tumors increasing (higher tumor size) versus only 2 to 3 percent of estrogen receptor positive tumors changing. Since stage is linked with survival rates, this study also supports earlier surgery, especially for people with triple negative or HER2 positive tumors.
Summary of Surgery Timing
Though we don’t have a solid answer on how soon surgery should be done after a diagnosis of breast cancer (it would be unethical to conduct a definitive study), it would seem earlier surgery is ideal (though taking a short time to plan is equally as important).
Delaying for a lengthy period of time can be dangerous, with studies finding that those who delay over six months are twice as likely to die from the disease. This is important to keep in mind for those who have breast lumps they are “observing” without a clear diagnosis. Any breast lump needs to be explained.
The Issue of Anxiety
Aside from differences in survival, anxiety can be one reason to schedule surgery sooner rather than later. Everyone is different when it comes to the level of anxiety experienced. Some people feel very comfortable waiting, whereas others feel very anxious, not wanting to “walk around with cancer in their body.” Studies have found that the times when women (and men) are most prone to anxiety are when waiting for biopsy results, and when waiting for treatment to begin. Those who are feeling anxious should probably consider having surgery earlier rather than later.
Time to Chemotherapy After Surgery
After surgery for early-stage breast cancer, many women also have adjuvant chemotherapy (and fortunately, genetic testing is helping to define those who need this and those who don’t).
For those who receive adjuvant chemotherapy, it’s thought to reduce the risk of death by 30 percent to 40 percent. The period of time between surgery and chemotherapy depends somewhat on how well someone does with surgery since the surgical site needs to be relatively well-healed before chemotherapy begins. But once the incision(s) are healed, what is the optimal time to begin this treatment?
Results have varied depending on the study, but as with surgery, a delay in chemotherapy appears to be more detrimental for those who have triple negative and HER2 positive tumors and should ideally be started within 30 days of surgery.
Adjuvant Chemotherapy Timing
A 2016 Systematic Review published in Breast Cancer Research and Treatment found that waiting more than four weeks increased the risk of recurrence and lowered survival (4 percent to 8 percent lower). Some other studies have not found a difference when chemotherapy was delayed more than four weeks, but did see lower survival with longer delays.
As with surgery, some people probably benefit more than others from pursuing adjuvant chemotherapy as soon as possible. A 2014 study found that delaying surgery more than 61 days after surgery lowered survival, with survival 75 percent lower in those with stage III disease. A 2018 study found that beginning chemotherapy within 30 days of surgery increased survival (compared with waiting 60 days), but only for those who had triple negative tumors or lymph node positive tumors.
Ideally, it would seem that chemotherapy should be started if at all possible within 30 days of surgery, especially for those who have high risk tumors.
Time to Treatment With Metastatic Breast Cancer
There is little research looking at the optimal time until treatment for metastatic breast cancer, though it appears that waiting more than 12 weeks has been linked with lower survival. In general, however, the goal of treatment with MBC is different than early stage disease. For most people, treatment for early-stage disease is aggressive, with the goal to reduce the risk of recurrence. With MBC, the goal is often to use the least amount of treatment necessary to control the disease.
Coping With Waiting
There are times when it can be challenging to schedule your surgery promptly after diagnosis. Some of these include:
Insurance and Scheduling Problems
Some people find that the surgeon they’ve chosen under their insurance company isn’t available for longer than they would like to wait, or that it’s difficult to coordinate a surgeon and plastic surgeon on the same day in a reasonable amount of time. This can be more difficult some places than others. With the larger cancer centers, you may have a coordinator who will assist you in setting up appointments. In the community, you may need to do most of the legwork yourself.
Regardless, it’s important to be your own advocate. If you’re having difficulty, make sure to work with your insurance company. Sometimes they may cover a second or third tier provider if it’s the only option available for scheduling your surgery promptly (but you may need to make calls and be persistent). With some procedures, prior authorization is needed before scheduling can take place.
There are many breast cancer organizations that can assist you as well as help you make decisions. Support groups and online support communities are also an excellent option when it comes to questions and challenges along the way.
There are many options as well for those who are underinsured or uninsured, but again, it’s usually up to you to do the legwork. Programs such as the SAGE program are available, as well as many other assistance programs that can help with anything from transportation to childcare. Talking to a social worker at your cancer center can be invaluable in learning about your options.
A Word From Verywell
While the best timing between diagnosis and surgery, and surgery and chemotherapy isn’t certain, it would seem earlier treatment (after taking time for things such as second opinions and healing from surgery) is ideal. Some of the research can be confusing (especially when you are newly diagnosed and just learning about things such as HER2), but having an understanding of your particular cancer and your individual preferences are important in making an educated choice about the best timing for your treatment.