The American Journal of Surgery (2014) 207, 686-692

North Pacific Surgical Association

Influence of nurse navigation on wait times forbreast cancer care in a Canadian regionalcancer center

Christopher Baliski, M.D.a,b,*, Colleen E. McGahan, M.Sc.b,c, Caitlyn M. Liberto, B.Sc.a,Sandra Broughton, M.Sc.a, Susan Ellard, M.D.a, Marianne Taylor, M.D.a,Janet Bates, B.Sc.N.a, Anky Lai, M.Sc.b,c

aBC Cancer Agency (BCCA SAH-CSI), Kelowna, BC, Canac

da; bSurgical Oncology Network, BCCA, Vancouver, BC,Canada; Cancer Surveillance & Outcomes, BCCA, Vancouver, BC, Canada

KEYWORDS:Breast cancer;Surgery;Wait time;Nurse navigation;MRI

There has been no previous suppor

involved in the manuscript.

The authors declare no conflicts of i

* Corresponding author. Tel.: 11-2

3911.

E-mail address: cbaliski@bccancer.b

Manuscript received November 7, 20

2014

0002-9610/$ - see front matter � 2014

http://dx.doi.org/10.1016/j.amjsurg.20

AbstractBACKGROUND: The wait times for breast cancer care in our region do not meet acceptable bench-

marks. We implemented the Interior Breast Rapid Access Investigation and Diagnosis (IB-RAPID)nurse navigation program to address this issue.

METHODS: The IB-RAPID prospective database was reviewed for patients entering the program be-tween April 1, 2011 and April 30, 2012 (2011/2012 cohort), and was compared with patients from thesame area in 2010. The main end point was the time between the 1st diagnostic imaging test and thesurgery. Multiple linear regression was performed to investigate factors influencing the wait times.

RESULTS: The wait times decreased with the introduction of IB-RAPID (59 vs 48 days; median).Stage of disease, total number of biopsies, and magnetic resonance imaging (MRI) use influenced waittimes. MRI significantly delayed surgical intervention in both groups with those not having an MRIhaving a shorter wait time to surgery (68.5 vs 57.6 days; mean) in 2011/2012.

CONCLUSION: The implementation of nurse navigation for patients with breast cancer appears to beeffective at reducing the wait times for surgical treatment.� 2014 Elsevier Inc. All rights reserved.

Breast cancer is the most common malignancy inCanadian women. Although outcomes are improving, ev-idence suggests that increasing wait times for treatment1

are likely related to increasingly complicated care pathsand competition for resources. In addition, waiting for

t for this project, nor any others

nterest.

50-712-3966; fax: 11-250-712-

c.ca

13; revised manuscript January 5,

Elsevier Inc. All rights reserved.

14.01.002

results and treatment is extremely stressful to both patientsand family, further magnifying this issue.2–4

Although excessive wait times for cancer care have beenlinked to poorer outcomes,5,6 there is controversy over thisissue and what is deemed an appropriate wait time is a matterof debate. A number of groups have suggested wait targets fortreatment in their guidelines7,8 with different recommenda-tionsdependingon the time interval of concern,with somesug-gesting comprehensive wait time targets from the time of 1stindication of an imaging abnormality, while others focusingon the time from pathologic confirmation of malignancy.9

Previous Canadian population-based studies have sug-gested that bench marks for cancer surgery are not being

C. Baliski et al. Nurse navigation on wait times for breast cancer care 687

reached. Several studies have shown wait times that aresignificantly longer than recommended1,10,11 with trends tolonger waits in later years.11,12 In our institution, we havealso found this to bean issue,which isof concern.13 In responseto this problem there have been efforts to streamline the carepath, which appears to be effective in reducing wait times,14–16with one group utilizing an integrated health system,14whileothers using nurse navigators to accomplish this goal.15,16

Based on our findings of prolonged wait times for breastcancer surgical care in our region, we instituted a program toaddress this. Funding through the BC Cancer Foundation wasused for a pilot project focused on both improving wait timesand patient satisfaction with care. The Interior Breast RapidInvestigation and Diagnosis Program (IB-RAPID) was insti-tutedwithin the referral center,with the largest volumeof breastsurgical cases in the region. Patients are referred to the programby Family Physicians after an abnormalmammogram, or whena patient presents with findings that are highly suspicious forbreast cancer. The program is organized by a nurse navigatorwho has a number of roles, including facilitating all relevantimaging tests and image-guided biopsies, and obtainingpathology reports, along with expediting surgical referrals. Inaddition, they provide information and support to patients andfamily, in the form of one-on-one meetings, along with groupeducational events involving other health care providers.

The purpose of this study was to determine the impact thatIB-RAPID has had on wait times for care in our center, and toidentify areaswhere improvements canbemade in the carepath.

Methods

The IB-RAPID prospective database was reviewed forpatients undergoing surgery between April 1, 2011 and April30, 2012 (2011/2012 cohort). We have previously reviewedthe wait times for patients referred to the BC Cancer AgencySindi Ahluwalia Hawkins Centre for the Southern Interiorbetween January 1st and December 31st in 2010.13 From thisgroup of patients we were then able to identify all patientswho had all imaging, biopsies, and surgeries within KelownaGeneral Hospital, and living in the same geographic referralarea as patients currently eligible for IB-RAPID (2010Cohort). University of British Columbia Research EthicsBoard approval was obtained for the study.

All female patients undergoing a definitive surgicalprocedure, with all preoperative breast imaging and bi-opsies performed in Kelowna General Hospital and livingin the Kelowna area, were eligible for inclusion in thestudy. Exclusion criteria included those patients undergoingimaging, biopsy, or surgery outside of Kelowna, recurrentor metastatic breast cancer, another concurrent cancer, orlocally advanced cancer (including inflammatory or T4breast cancer, and use of neoadjuvant therapy).

Time intervals of interest for the study included timesfrom the following:

1. First diagnostic imaging test to 1st biopsy (wait 1)2. First biopsy to pathological diagnosis (wait 2)

3. Pathological diagnosis to 1st definitive surgery (wait 3)4. First diagnostic imaging test to 1st definitive surgery

(Comprehensive wait)

Univariate analysiswas performed to investigate patient anddisease characteristic differences between the 2 study cohorts.Comparisonsweremade using the t test for continuous charac-teristics and Pearson chi-square tests for categorical character-istics. Fisher exact test was used for categorical characteristicswith small frequencies. Variables assessed include patient ageat diagnosis, stage of disease, number and type of imaging testreceived (mammogram, ultrasound, and/or magnetic reso-nance imaging [MRI]), 1st indication of disease, number andtype of diagnostic biopsies, type of breast surgery, and use ofimmediate breast reconstruction. Multiple linear regressionwas performed to investigate which of these factors influencedthemain outcome of interest – time from the 1st diagnostic im-aging test to the 1st definitive surgery. The natural log of thetime from the 1st diagnostic imaging to the 1st definitive breastsurgery was used in the model to overcome the lack ofnormality.Because of the relationship between someof thevar-iables of interest (ie, the number of imaging tests received andthe use of mammogram, ultrasound, and MRI), Akaike Infor-mation Criteria with correction was used and the model withthe lowest Akaike Information Criteria with correction valuewas selected to be the finalmodel.All analyseswere performedusing SAS Version 9.3 (SAS Institute, Inc, Cary, NC).

Results

There were 97 patients in the IB-RAPID cohort, and 100patients in 2010 who met inclusion criteria. On univariateanalysis, the groups were comparable in all respects, exceptin the use of imaging and 1st indication of disease(Table 1). The age, stage, number of biopsies, attempts atbreast conservation surgery, and the use of reconstructionwere similar between the 2 groups.

The comprehensive wait time from 1st imaging to surgicalintervention was shorter for patients in 2011/2012 (48 vs59 days; median) than those in 2010 (Fig. 1). Themedian timefrom 1st imaging to obtaining the 1st diagnostic biopsy (10 vs13 days; median), and from pathologic diagnosis to surgery(32 vs 38 days; median) was shorter in 2011/2012 contrib-uting to the improvement in comprehensive wait times. Therewas no difference in the time frame from biopsy to pathologicdiagnosis (wait 2) between the 2 groups (4 days; median).

On multivariate analysis, the factors that influenced thecomprehensive wait time included the stage of disease andtotal number of biopsies (Table 2). Patients with Stage 0 dis-ease (ductal carcinoma in situ) and those requiring more bi-opsies waited longer for surgery. There was no difference inthe adjusted mean wait time for surgery between 2010 and2011/2012 (78 vs 87 days; adjusted mean). The use of MRIhad the greatest impact on the wait time in patients, withthose undergoing MRI in 2011/2012 having surgery de-layed more than 6 weeks (133 vs 88 days; adjustedmean). Paradoxically, in patients not undergoing an MRI,

Table 1 Patient characteristics by study cohort

Cohort 1 (2010) Cohort 2 (IB-RAPID) Total

All 100 97 197Mean SD Mean SD P value

Age (years) 63.5 13.6 63.5 12.3 .9802n % n %

Final stage0 12 12.0 7 7.2 .2671I 51 51.0 42 43.3II 28 28.0 39 40.2III 9 9.0 9 9.3

Use of mammogramNo 12 12.0 3 3.1 .0184Yes 88 88.0 94 96.9

Use of ultrasoundNo 15 15.0 6 6.2 .0450Yes 85 85.0 91 93.8

Use of MRINo 95 95.0 91 93.8 .7171Yes 5 5.0 6 6.2

Total imaging techniques1 26 26.0 9 9.3 .00842 70 70.0 82 84.53 4 4.0 6 6.2

First indicationPatient discovered lump 37 37.0 33 34 .0029Physician discovered 7 7.0 6 6.2Screening 53 53.0 39 40.2Symptom 3 3.0 19 19.6

First biopsy typeFNA 2 2.0 2 2.1 .9400*WLB 7 7.0 4 4.1Core mammatome 11 11.0 10 10.3Core surgeon 5 5.0 4 4.1Core ultrasound 75 75.0 77 79.4

Total biopsies performed1 93 93.0 85 87.6 .20172 7 7.0 12 12.4

Type of 1st oncologic procedureNodes only 1 1.0 0 0 .7130*Segmental mastectomy 34 34.0 30 30.9Segmental mastectomy WL 28 28.0 27 27.8Skin sparing 2 2.0 5 5.2Total mastectomy 35 35.0 35 36.1

ReconstructionNo reconstruction 95 95.0 91 93.8 .7171Reconstruction 5 5.0 6 6.2

FNA 5 fine needle aspirate; IB-RAPID 5 interior breast rapid access investigation and diagnosis; MRI 5 magnetic resonance imaging; SD 5 standard

deviation; WL 5 wire localized; WLB 5 wire localized biopsy.

*Fisher exact test used.

688 The American Journal of Surgery, Vol 207, No 5, May 2014

the trend was shorter wait times in 2011/2012 (58 vs69 days; adjusted mean).

Comments

The wait times for surgery are a major concern for allpatients, but no more so than in those awaiting cancer care.

The combination of more sophisticated diagnostic work-upand increased competition for access to resources hasinfluenced the ability to provide timely care. This isespecially an issue in publicly funded health care systems,which are challenged with the costs associated with anaging population and changes in technology. As a result, anumber of groups have developed guidelines around theappropriateness of wait times. European Society of Breast

Figure 1 Median time intervals between treatments for womenwith newly diagnosed breast cancer in 2010 and 2011/2012 co-horts. The 1st and 3rd quartiles are listed in brackets.

C. Baliski et al. Nurse navigation on wait times for breast cancer care 689

Cancer Specialists has recommended that 75% of patientsundergo surgery within 6 weeks of 1st diagnostic imag-ing,17 while according to the National Institute for Healthand Care Excellence guidelines, 100% of patients shouldundergo surgery within 31 days.8 This in turn has led to anumber of reports focusing on the wait times for care in in-dividual institutions and regional cancer centers to deter-mine where they are with respect to suggestedbenchmarks for care.

There have been several reports focusing on population-based provincial wait times for breast cancer care in Canada(Fig. 2). Mayo et al11 reviewed the comprehensive wait timesfrom abnormal diagnostic imaging to surgery and found thatthe median wait time for surgery was 34 days. The wait times

Table 2 Factors influencing surgical wait times (least square means

Number of observationsin final model

Year2010 Cohort 1002011/2012 Cohort 97

Final stage0 19I 93II 67III 18

MRINo 186Yes 11

Total biopsies performed1 1782 19

Year ! MRICohort 1 ! MRI 5 No 95Cohort 1 ! MRI 5 Yes 5Cohort 2 ! MRI 5 No 91Cohort 2 ! MRI 5 Yes 6

CI 5 confidence interval; MRI 5 magnetic resonance imaging.

increased in later years, ranging from 29 days in 1992 to42 days in 1998. Similar results were also found by Raysonet al,1 with wait times increasing between 1999 and 2004. Anumber of intervals of care were assessed, with the timefrom breast biopsy to surgery increasing over this time period(21 vs 17 days; median). Although not explicitly stated in theirstudy, the wait time from imaging to surgery appeared to besimilar (36 days; estimated) to that reported by Mayo et al.

Similar to other regions in Canada, we have also foundwait times to be a comparable issue.13 At our regional can-cer center (BC Cancer Agency Sindi Ahluwalia HawkinsCentre for the Southern Interior), the comprehensive waittimes trended longer (50 vs 53 days; median) between2006 and 2010. During this time period, wait 3 was longer(30 vs 26 days; median), while wait 1 decreased (20 vs13 days; median). Before 2010, a provincial initiativeoccurred to improve access to imaging throughout the prov-ince which likely improved wait 1, likely keeping thecomprehensive wait times in check over this time period.

Although the comprehensive wait times for surgery areof relevance to patients, health care providers, and policymakers, there is a strong focus on health care in the waittimes for surgery once a pathologic diagnosis is identified(wait 3). There are constant pressures to minimize this timeperiod, and in Canada the suggested wait time for cancersurgery from the time of diagnosis is 14 days, as set out bythe Canadian Society of Surgical Oncology (CSSO).9 Thewait times in all provinces are longer than those recommen-ded (Fig. 3). Simunovic et al10 reported a median wait timeof 20 days between decision to treat and surgery, whileothers reported wait times ranging between 17 and

)

Least squaresmean (d) Lower 95% CI Upper 95% CI

77.7 61.5 98.287.4 71.3 107.1

105.3 82.1 135.180.6 67.4 96.370.8 59.0 85.076.7 59.1 99.5

62.8 55.9 70.6108.0 81.1 144.0

72.4 61.9 84.793.7 73.9 119.0

68.5 59.8 78.588.1 57.9 134.157.6 50.4 65.8132.5 91.4 192.1

Figure 3 Comparison of studies of median wait time from 1stdiagnostic imaging test to 1st oncologic surgery. * Calculatedcomprehensive wait (added several interval medians to come upwith that number). ** Mean wait time.

Figure 2 Comparison of studies of median wait time from path-ologic diagnosis to 1st oncologic surgery. * Mean wait time.

690 The American Journal of Surgery, Vol 207, No 5, May 2014

22 days,1,12 with one group also finding increasing waittimes in later years.

As previously mentioned, the wait time for surgery (wait3) appears to be an issue in our region with longer waits inrecent years (26 vs 30 days; median), and longer thanreported in other provinces13 in Canada. This was espe-cially true in the highest volume surgical center in the re-gion (Kelowna), with wait times longer (38.5 vs 30 days;median) than those in the other hospitals in the region in2010 (Results not published). This finding was the impetusto find a solution in our hospital and region.

It is recognized that the diagnostic and treatment pathwayfor breast cancer is complex with multiple steps and careprocesses. This is evident in our cohort of patients, as wefound that the need for a 2nd diagnostic biopsy, although notcommon, increased the time to surgery by 3 weeks (Table 2).In addition, the use of preoperative MRI resulted in longerwaits for surgery as has been identified by some,18,19 butnot in all institutions.20 Although we do not commonly utilizepreoperativeMRI in our patients, it prolonged the comprehen-sive wait time for surgery between 2 and 6 weeks, necessi-tating this as an area to focus on in our institution and withour program. Although the use of immediate reconstructiondid not appear to influence thewait time for surgery in patientswithin our local area, both we13 and others have also foundthis to delay definitive surgical treatment.21

To guide patients through this complex care pathway, anumber of organizations have developed guidelines formanagement of breast cancer with one of the qualityindicators being access to timely diagnosis and treatment.Landercasper et al14 found that with an integrated breast cen-ter, patients could have their surgical consultation and surgicaldate within 10 working days of a pathologic diagnosis.Although care provided within privatized health care in theUnited States is not directly comparable to publicly fundedhealth care, it does show what is possible with managementcare paths and support staff dedicated to this process. Amore comparable approach has been reported by Arnaoutet al,15 who implemented a nurse navigation program verysimilar to the one we have implemented. They were able todecrease the wait time for all intervals of care (waits 1, 2,and 3), and although the comprehensive wait was not re-ported, we estimate that they have improved on this as well

(36 vs 59 days; mean). These results appear remarkablysimilar to those found in our initiative, where we were alsoable to decrease the wait time (48 vs 59 days; median).

Similar to the results reported by Arnaout et al, we wereable to reduce our comprehensive wait time to a median of48 days within the 1st year of the introduction of theprogram without any change, other than the introduction ofa nurse navigation program. Through a review of thecomponents of care, we were able to identify factors thatinfluenced wait times. The need for a repeat diagnosticbiopsy increased the wait time by almost 3 weeks in ourinstitution. Although preoperative MRI utilization is low inour patients with early breast cancer, it delayed surgeryfrom 2 to 6 weeks, which has been identified to be an issuein some18,19 but not all reviews of this subject.20 This wasparticularly an issue in more recent years, as we found thatpatients having an MRI had longer waits after the introduc-tion of the program, while those without MRI tended tohave a shorter wait. This may be a result of the requirementfor a surgeon to order a breast MRI in our institution. SinceMRI use in our population is so low, and addressing thewait time for preoperative MRI is easily rectified in ourinstitution, we believe the shorter adjusted mean wait timesin the non-MRI IB-RAPID cohort reflects an overall posi-tive effect of the program. Unlike previous findings by our-selves13 and others,21 we did not find that the use ofimmediate reconstruction delayed surgical intervention inthis study, but likely requires further study.

It appears that having either awell-defined care process oran individual tasked with guiding patients through the healthcare system appears to enable a faster transition to surgery. Acomprehensive review of the components of care also allowsfor an analysis of barriers to timely care, which in our regionappears to be the need for repeat biopsy and the use ofMRI inour institution. This suggests that nurse navigation programsare effective in reducing overall wait times for cancer care,especially in a publically funded health care model.

Although the wait times for care in patients with breastcancer are an area of concern, ultimately the effect this hason patients’ well-being, namely anxiety and satisfaction, isthe real focus. Institutions that have implemented nurse

C. Baliski et al. Nurse navigation on wait times for breast cancer care 691

navigation or streamlined care paths have found that theyimproved patient satisfaction.14,15 Although minimizing thewait times for investigation and treatment are very impor-tant to patients, they also value communication and caring.It is likely that both of these factors contribute to the pa-tients’ perception of their care path. We are currently inthe process of investigating the role that nurse navigationhas on patient satisfaction within our center.

References

1. Rayson D, Saint-Jacques N, Younis T, et al. Comparison of elapsed

times from breast cancer detection to first adjuvant therapy in Nova

Scotia in 1999/2000 and 2003/04. CMAJ 2007;176:327–32.

2. Rozema H, Vollink T, Lechner L. The role of illness representations in

coping and health of patients treated for breast cancer. Psychooncol-

ogy 2009;18:849–57.

3. Green BL, Rowland JH, Krupnick JL, et al. Prevalence of posttrau-

matic stress disorder in women with breast cancer. Psychosomatics

1998;39:102–11.

4. Tjemsland L, Soreide JA. Operable breast cancer patients with diag-

nostic delay–oncological and emotional characteristics. Eur J Surg On-

col 2004;30:721–7.

5. Richards MA, Westcombe AM, Love SB, et al. Influence of delay on

survival in patients with breast cancer: a systematic review. Lancet

1999;353:1119–26.

6. Lohrisch C, Paltiel C, Gelmon K, et al. Impact on survival of time

from definitive surgery to initiation of adjuvant chemotherapy for

early-stage breast cancer. J Clin Oncol 2006;24:4888–94.

7. Del Turco MR, Ponti A, Bick U, et al. Quality indicators in breast can-

cer care. Eur J Cancer 2010;46:2344–56.

8. National Institute of Health and Clinical Excellence. Early and locally

advanced breast cancer: diagnosis and treatment (Clinical guideline

80). Available at: http://www.nice.org.uk/CG80. Accessed November

14, 2013.

9. CSSO Position Statement. Available at: http://cos.ca/csso/?s5position1statement&submit5Search. Accessed June 30, 2013.

10. Simunovic M, Gagliardi A, McCready D, et al. A snapshot of waiting

times for cancer surgery provided by surgeons affiliated with regional

cancer centres in Ontario. CMAJ 2001;165:421–5.

11. Mayo NE, Scott SC, Shen N, et al. Waiting time for breast cancer sur-

gery in Quebec. CMAJ 2001;164:1133–8.

12. Reed AD, Williams RJ, Wall PA, et al. Waiting time for breast cancer

treatment in Alberta. Can J Public Health 2004;95:341–5.

13. Liberto C, Baliski C, McGahan C, et al. Comparison of breast cancer

treatment wait times in the southern interior BC in 2006 and 2010. Can

J Surg 2012;55:54.

14. Landercasper J, Linebarger JH, Ellis RL, et al. A quality review of the

timeliness of breast cancer diagnosis and treatment in an integrated

breast center. J Am Coll Surg 2010;210:449–55.15. Arnaout A, Smylie J, Seely J, et al. Improving breast diagnostic ser-

vices with a rapid access diagnostic and support (RADS) program.

Ann Surg Oncol 2013;20:3335–40.16. Basu M, Linebarger J, Gabram SG, et al. The effect of nurse naviga-

tion on timeliness of breast cancer care at an academic comprehensive

cancer center. Cancer 2013;119:2524–31.17. Wilson AR, Marotti L, Bianchi S, et al. The requirements of a

specialist breast centre. Eur J Cancer 2013;49:3579–87.18. Bleicher RJ, Ciocca RM, Egleston BL, et al. Association of routine pre-

treatmentmagnetic resonance imagingwith time to surgery,mastectomy

rate, and margin status. J Am Coll Surg 2009;209:180–7; quiz, 294–5.19. Hulvat M, Sandalow N, Rademaker A, et al. Time from diagnosis

to definitive operative treatment of operable breast cancer in the

era of multimodal imaging. Surgery 2010;148:746–50; discussion,

750–1.

20. Angarita FA, Acuna SA, Fonseca A, et al. Impact of preoperative

breast MRIs on timing of surgery and type of intervention in newly

diagnosed breast cancer patients. Ann Surg Oncol 2010;17(Suppl 3):

273–9.

21. Vandergrift JL, Niland JC, Theriault RL, et al. Time to adjuvant

chemotherapy for breast cancer in national comprehensive cancer

network institutions. J Natl Cancer Inst 2013;105:104–12.

Discussion

John Vetto, M.D.: This Association is a particularlyappropriate forum to discuss the issue of surgical wait timesfor cancer patients because it spans 2 countries where thisissue is at least perceived as being approached differently.Traditionally, in Canadawait times are longer because of a na-tional health service; the authors present a table in the manu-script that shows that published wait times for breast canceroperations from tissue diagnosis in Canada vary from 14 to35 days, compared to an average of 10 days in the US and arecommendation of no more than 14 days from the CanadianSociety of Surgical Oncology.

The authors begin their paper with the fundamentalquestion: do surgical wait times affect outcomes in cancer?They simply note that while there is some literature tosupport this idea, it is controversial. It is possible thatlonger wait times do affect the outcomes of cancers that arestill mostly Halstedian, such as locally advanced mela-nomas and soft tissue sarcomas. In the case of more a non-Halstedian cancer such as breast, and especially in this ageof neoadjuvant therapy, one can argue that wait timesactually may not be as important. However, at least in theUS, patients and the legal profession have voted with theirfeet, so the issue is probably moot.

The authors continue the manuscript with a laudatorydiscussion of the shorter wait times in the US, a phenomenawhich has obviously been driven by free market competi-tion and patient pressure. Avoiding a discussion of thepossible affect on that track record by the AffordableHealth Care Act, I will instead skip to the fact that theauthors chose to attribute US success in part to the use ofnurse navigators to track, discuss, and facilitate thescheduling of operation.

I think the authors assumption that the use of nursenavigators has been a factor in shorter US wait times iscorrect; as they show in one of their tables, when onebreaks down time to operation into separate subevents(imaging to biopsy, biopsy to diagnosis, and diagnosis tooperation) it is diagnosis to operation that took the longest.The use of the IB-RAPID protocol using nurse navigatorsshortened this from a mean of 37 to a mean of 33 days, andresulted in an overall reduction of imaging to operationtime of 59 to 48 days. Although these numbers are stillsurprisingly high, one should note that the authors chose tomeasure wait time from imaging to operation rather thanthe usual diagnosis to operation used in the literature. Isalute the authors for looking so critically at this issue, fortheir honest statement that these wait times are too long,

692 The American Journal of Surgery, Vol 207, No 5, May 2014

and for reporting what is basically negative data: theimprovement seen in wait times did not reach statisticalsignificance. Because nurse navigators were paid for in thisstudy by a grant from the BC Cancer Foundation onewonders if and how they will be paid for in the future.

This study raises other issues. It would be interesting toknow what barriers prevented further shortening of waittimes, and how the authors will overcome these. Further,

their data suggests that the use of breast MRI increased waittimes. How should this information impact MRI use?Finally, looking at the tables, the longest subintervalremains pathologic diagnosis to operation. Some of thismay in part be due to coordination with Plastic surgery forthose patients who choose extensive reconstruction, and itwould also be interesting to know if the extent of theoperation planned affected the data.