A total of 531,644 patients met inclusion criteria. Overall, 340,297 (64.0%) received FC while 191,347 (36.0%) received non-FC care. Baseline patient demographics, tumor characteristics and treating facility types are shown in Table 1. Patients receiving FC were more likely to be younger (mean age 63.2 vs 65.4 years, p < 0.0001), non-Hispanic White (82.5% vs 81.2%, p < 0.001), and have private insurance/managed care (49.9% vs 43.6% (p < 0.0001). Receipt of FC was more common in patients with AJCC stage II or stage III disease (26.5% vs 25.7%, p < 0.0001) and hormone receptor (HR) positive tumors (88.0% vs 87.1%, p < 0.0001). Treatment delay was more prevalent in patients with FC (12.1% vs 9.9%, p < 0.0001).

Patients diagnosed and treated at a single institution were more likely to receive care at a comprehensive community cancer program (45.0% vs 42.4%, p < 0.0001) or academic/research program (30.6% vs 28.1%, p < 0.0001), have stage I disease (74.3% vs 73.5%, p < 0.0001), and have surgery within 60 days of diagnosis (90.1% vs 87.9%, p < 0.0001).

After adjustment, multiple factors were independently associated with treatment delay. Patient characteristics included Hispanic (OR 1.82, 95% CI: 1.76–1.88), non-Hispanic Black (OR 1.82, 95% CI: 1.77–1.87), and Asian/other race and ethnicities (OR 1.25, 95% CI: 1.20–1.31) as well as those with Medicaid insurance (OR 1.89, 95% CI: 1.83–1.95), uninsured status (OR 1.72, 95% CI: 1.62–1.83), Medicare (OR 1.11, 95% CI: 1.08–1.14), and other Government insurance (or 1.30, 95% CI: 1.20–1.41), and lower education levels, with the greatest risk in patients residing in zip codes with at or above 15.3% without high school diplomas (OR 1.47, 95% CI: 1.43–1.52). In terms of treatment facility, those treated at academic/research programs (OR 1.59, 95% CI: 1.53–1.65), integrated network cancer programs (OR 1.42, 95% CI: 1.36–1.48), and comprehensive community cancer programs (OR 1.17, 95% CI: 1.13–1.22) had increased odds of treatment delay compared to community cancer programs. Patients with AJCC stage II (OR 1.15, 95% CI: 1.13–1.18) and AJCC stage III tumors (OR 1.15, 95% CI: 1.09–1.22) had increased odds of treatment delay compared to AJCC stage I tumors. Receipt of FC (OR 1.27, 95% CI: 1.25–1.29) was independently associated with delayed treatment as well (Table 2).

Younger age (OR 0.99, 95% CI: 0.99–0.99), lower income status– with levels of less than $46,277 having lowest odds (OR 0.81, 95% CI 0.78–0.83), and tumors with HR-/HER2 + receptor status (OR 0.87, 95% CI: 0.82–0.91) and triple negative receptor status (OR 0.73, 95% CI: 0.71–0.76) were independently associated with lower likelihood of treatment delay (Table 2).

After adjustment, multiple factors were independently associated with FC. Patient characteristics included Hispanic ethnicity (OR 1.04, 95% CI: 1.01–1.07), those with Medicare insurance (OR 1.04, 95% CI: 1.02–1.06), other Government insurance (OR 1.35, 95% CI: 1.27–1.43), and lower education levels, with the greatest risk in patients residing in zip codes with at or above 15.3% without high school diplomas (OR 1.28, 95% CI 1.26–1.31). Compared to treatment at community cancer programs, treatment at integrated network cancer programs (OR 1.55, 95% CI: 1.51–1.59) and comprehensive community cancer programs (OR 1.06, 95% CI: 1.03–1.08) were independently associated with FC. Patients with AJCC stage II (OR 1.06, 95% CI: 1.05–1.07) and stage III (OR 1.06, 95% CI: 1.02–1.10) tumors and HR + /HER2 + receptor status (OR 1.05, 95% CI: 1.02–1.07) also had increased odds of receiving FC (Table 3).

Patient factors predictive of non-FC care included younger age (OR 0.98, 95% CI 0.98–0.98), non-Hispanic Black race and ethnicity (OR 0.78, 95% CI: 0.77–0.80), uninsured status (OR 0.62, 95% CI: 0.58–0.65) those with Medicaid insurance (OR 0.83, 95% CI: 0.80–0.85), and those with lower income status—with income lower than $46,277 having greatest association (OR 0.73, 95% CI: 0.72–0.75). Tumor characteristics including HR-/HER2 + receptor status (OR 0.95, 95% CI: 0.92–0.98) and triple negative receptor status (OR 0.94, 95% CI: 0.92–0.95) had lower odds of FC. Patients receiving definitive surgical treatment within 60 days of diagnosis also had lower likelihood of FC (Table 3).

Patient factors independently associated with lower likelihood of mortality included Hispanic (HR 0.73, 95% CI: 0.70–0.76) and Asian/ other race and ethnicities (HR 0.71, 95% CI: 0.68–0.75). Compared to treatment at community cancer programs, treatment at academic/research programs (HR 0.80, 95% CI: 0.78–0.82), comprehensive community cancer programs (HR 0.93, 95% CI: 0.91–0.95), and integrated network cancer programs (HR 0.90, 95% CI: 0.88–0.93) were associated with reduced mortality (Table 4). Patients receiving FC had lower likelihood of mortality compared to those with non-FC care (HR 0.87, 95% CI: 0.86–0.88) as shown in Fig. 2.

Kaplan Meier survival curves for patients with stage I-III breast cancer receiving definitive surgery after diagnosis, stratified by care structure (FC vs non-FC)

Delay in treatment greater than 60 days was independently associated with increased risk of mortality (HR 1.23, 95% CI 1.20–1.26) as shown in Fig. 3. Patient age (HR 1.07, 95% CI: 1.07–1.07), non-Hispanic Black race and ethnicity (HR 1.08, 95% CI: 1.05–1.10), Medicaid insurance (HR 1.75, 95% CI: 1.69–1.81), lower income—with the greatest risk at income level below $46,277 (HR 1.27, 95% CI: 1.24–1.30), lower education levels—with the greatest risk in patients residing in zip codes with 9.1%–15.2% without high school diplomas (OR 1.10, 95% CI: 1.08–1.13), AJCC stage II tumors (HR 1.80, 95% CI: 1.77–1.82), AJCC stage III tumors (HR 3.46, 95% CI: 3.36–3.56), HR+/HER2 + receptor status (HR 1.21, 95% CI: 1.18–1.24), and Charlson-Deyo score I (HR 1.44, 95% CI: 1.41–1.46), Charlson-Deyo score II (HR 2.09, 95% CI: 2.03–2.15) and Charlson-Deyo score III (HR 3.01, 95% CI: 2.90–3.13) were independently associated with higher risk of mortality (Table 4).

Kaplan Meier survival curves for patients with stage I-III breast cancer receiving definitive surgery after diagnosis, stratified by time to treatment (<=60 vs > 60 days)