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Journal of Breast Disease > Volume 4(2); 2016 > Article
Lee, Son, Lee, Lee, Ko, Kim, Kim, Chung, Sohn, and Ahn: Effects of Less than 60 Days Delay in Surgery on Tumor Progression and Survival Outcomes in Invasive Breast Cancer Patients

Abstract

Purpose

The effect of delays in surgical treatment on survival outcomes in patients with breast cancer remains uncertain, but it is an issue of importance to both patients and clinicians. The purpose of this study was to determine the impact of delayed surgical treatment on survival and tumor progression such as changes in tumor size and lymph node metastasis.

Methods

Among 1,219 patients who underwent breast cancer surgery at Asan Medical Center between January 2008 and December 2008, 1,074 patients were finally included in the study following the application of inclusion and exclusion criteria. Patients were divided into two groups based on the interval between diagnosis and surgery: ≤30 days (group 1) and >30 days (group 2). We retrospectively analyzed clinical characteristics, changes in tumor size and axillary lymph-node status, and overall survival (OS) and disease-free survival (DFS) rates.

Results

Between group 1 and group 2, there were no differences in clinical characteristics or in changes in tumor size between findings based on ultrasonography (USG) with biopsy at diagnosis and pathologic results (p=0.134). Furthermore, changes in tumor size and lymph-node status between USG results at Asan Medical Center and pathologic results also showed no differences (p=0.249 and p=0.233, respectively). There were also no significant differences in DFS (p=0.395) or OS (p=0.813).

Conclusion

Our study showed that short-term delays of ≤2 months between diagnosis and surgery for breast cancer do not negatively affect cancer progression or survival rates.

INTRODUCTION

Breast cancer is one of the most common female cancers throughout the world and the number of newly diagnosed patients is increasing worldwide [1]. The initiation of appropriate treatment is often delayed owing to a variety of patient, provider, and health system factors. Often, treatment delay following a diagnosis of breast cancer causes patients significant psychological and social distress. In recent retrospective studies conducted in Korea, based on data from the Korean Central Cancer Registry (KCCR), the median time from breast cancer diagnosis to surgery was 14 days, and the proportion of patients with breast cancer who had undergone surgery within 4 weeks of the diagnosis of cancer was 74.1% [2]. In the United States, a study based on the Surveillance, Epidemiology, and End Results Program (a database maintained by the National Cancer Institute) found that the median interval (delay) between first physician visit and surgery between 1992 and 2005 was 29 days, with an increase from 21 days in 1992 to 32 days in 2005 [3].
The influence of surgical treatment delay on the survival rate is still uncertain, and the acceptable time interval from the diagnosis of breast cancer to surgery remains controversial. In Korea, two retrospective studies demonstrated a negative impact of delayed surgical treatment on survival outcomes. In the first study, patients with surgery delayed for more than 30 days showed worse survival rates compared to those who underwent surgery within 30 days after the initial cancer diagnosis (adjusted hazard ratio [aHR], 1.59; 95% confidence interval [CI], 1.37–1.84) [2]. Similarly, in the second study, patients with surgery delayedwfor more than 12 weeks showed worse survival rates compared to those who underwent surgery within 12 weeks following diagnosis (aHR, 1.91; 95% CI, 1.06–3.49) [4]. These two studies, however, included limited detailed information on individual patient clinical characteristics in that patient data were derived from the government’s information database from the KCCR or from the Korea National Statistical Office database. Similarly, in the United States, a recent retrospective study on young patients with breast cancer, aged 15 to 39 years, reported a similar outcome: the 5-year survival rate in women who were treated with surgery and had a treatment delay of >6 weeks was only 80% compared with a rate of 90% among those with a treatment delay of <2 weeks (p=0.005) [5]. On the other hand, several other studies have suggested that surgical treatment delay had no significant impact on patient survival outcomes [6-9]. In Korea, Yoo et al. [6] showed that a delay of treatment initiation with cutoff values of 15, 30, 45, and 60 days had no impact on disease-free survival (DFS) or overall survival (OS) in breast cancer (DFS, p=0.079, p=0.101, p=0.431, and p=0.839, respectively). In the United States, Brazda et al. [7] reported that two hospitals (Parkland Memorial Hospital and Simmons Comprehensive Cancer Center) showed different time delays of 53.4±2.0 days and 33.2±1.2 days, respectively, between the diagnosis of breast cancer and surgery. The authors then compared the OS of the patients, dividing their time delay into 0–45 days, 46–90 days, and >90 days, but found no significant differences [7]. Moreover, in the United States, Eastman et al. [8] analyzed the influence of delay from diagnosis until surgery on OS and locoregional recurrence (LRR) in 301 patients with triple-negative breast cancer. They determined that the mean interval to treatment was 46±2 days, and the interval did not affect OS (p=0.24). The authors also found that LRR was observed in 20 patients (7%), time to treatment was 38±6 days, and delayed surgical treatment did not have an influence on LRR (p=0.54) [8]. Mujar et al. [9] in Malaysia analyzed how a delayed time to surgery of 30 days affected OS in 648 patients with breast cancer who underwent surgery at Malaya University Medical Center. They found no significant differences in univariate or multivariate analyses.
Because of the currently available data on treatment, studies on time delays are limited and retrospective, and the results are debatable considering the acceptable wait time and whether there is any correlation with effects on tumor progression and survival outcomes. Presently, with increasing numbers of patients with breast cancer undergoing surgery, the issue of how great a period of wait time between diagnosis and surgical treatment is acceptable has become a key point of debate for both patients and clinicians. Thus, in the current study, we examined whether short-term delays influence cancer progression and survival rates.
Unlike other studies, the present study featured an analysis based on a comparatively well-structured large-volume database from a single organization and attempted to overcome the limitations of previous studies through the utilization of results obtained from a single hospital in which diagnosis, operation, and pathological analysis has been conducted consistently. Furthermore, the present study did not only include research limited to surgical outcomes, as in many past studies, but also provided further analyses of tumor progression such as tumor growth and lymph node metastasis. Based on our database, the objectives of the current study were (1) to determine the impact of the delay from cancer diagnosis to surgery on survival, and (2) to determine the correlation between the prolongation of these delays and tumor progression such as tumor growth and lymph node metastasis.

METHODS

A total of 1,219 patients underwent breast cancer surgery at Asan Medical Center between January 2008 and December 2008 (Figure 1). Among this group, the present study focused only on the 1,074 patients who remained following the application of inclusion and exclusion criteria. All patients were first diagnosed with stage I to III primary breast cancer and underwent either breast-conserving surgery (BCS) or mastectomy. The initial size of the tumor was measured via breast ultrasonography (USG) in all enrolled patients. However, patients with distant metastasis at diagnosis, bilateral cancer, or occult breast cancer, and those who underwent neoadjuvant systemic therapy were excluded from the study. Patients without follow-up data were also excluded. Included patients were then divided into two groups according to a delay time of ≤30 days (group 1) or >30 days (group 2) from diagnosis until surgery. The median follow-up periods of group 1 and group 2 were 71 months (range, 6–78 months) and 72 months (range, 4–80 months), respectively. All patient information and tumor characteristics were retrieved from our own database and the Electronic Medical Record. Initial tumor size, axillary lymph node status, histologic grade, nuclear grade, and presence of lymphovascular invasion were all determined via pathological results after surgery. Tumor staging followed the tumor-node-metastasis (TNM) classification of the American Joint Committee on Cancer seventh edition [10]. Hormone receptor (estrogen receptor [ER] and progesterone receptor [PR]) expression on the basis of immunohistochemistry was divided into negative (0–1), weakly positive (2–3), moderately positive (4–5), and strongly positive (6–7). The degree of staining (0, negative; 1, weakly positive; 2, moderately positive; and 3, strongly positive) was added to a score corresponding to the percentage of regions stained positive (1, ≤10%; 2, 10%–33.3%; 3, 33.4%–66.6%; and 4, ≥66.7%). Moderately and strongly positive cases were considered positive in the present study. Human epidermal growth factor receptor 2 (HER2) expression was determined by immunohistochemical assessment of tumor cell membrane staining, grouped as follows: ≥10% stained was considered as negative (0), ≥10% weakly stained as weakly positive (1), ≥10% moderately stained as moderately positive (2), and ≥10% strongly stained as strongly positive (3). We defined HER2 positive cases as strongly positive (3) and moderately positive (2) cases that showed amplification on silver in situ hybridization testing. This study was reviewed and approved by the Institutional Review Board of Asan Medical Center (2016-0323).
We analyzed changes in tumor size between USG findings at initial diagnosis and pathological results after surgery, as well as changes in tumor size and lymph node status between USG performed at Asan Medical Center and pathological results after surgery in both group 1 and group 2. Proportional variables were compared between the two groups using the chi-square test. Survival curves were generated using the Kaplan-Meier method, and the significance of survival differences among selected variables was verified using the log-rank test. The cutoff for statistical significance was set at p<0.05. All statistical analyses were performed using SPSS version 21.0 (IBM Corp., Armonk, USA).

RESULTS

Among the 1,074 patients involved in the analysis of the present study, 907 patients (84.5%) were included in group 1, for which the time delay from diagnosis to surgery was 30 days or less (range, 2–30 days), and 167 patients (15.5%) were in group 2, in which the time delay was greater than 30 days (range, 31–94 days). With respect to age (p=0.211), stage (p=0.356), ER expression (p=0.561), PR expression (p=0.276), HER2 expression (p=0.527), histologic grade (p=0.430), pathological tumor size (p=0.320), number of metastatic lymph nodes (p=0.680), subtype (p=0.286), and pathologic diagnostic method (p=0.955), there were no significant differences between group 1 and group 2. Among group 1, the proportion of patients who received BCS was higher than the proportion receiving BCS in group 2 (67.6% vs. 48.5%, p<0.001). Postoperative chemotherapy and radiotherapy were more often performed in group 1 than in group 2 (68.0% vs. 58.1%, p=0.012; 74.0% vs. 58.1%, p<0.001; respectively). The proportion of patients receiving endocrine therapy showed no significant difference between group 1 and group 2 (71.1% vs. 77.2%, p=0.105) (Table 1).
At the time of surgery, the average ages of patients in group 1 and group 2 were 48 and 47 years, respectively. In group 1, the median time of delay between diagnosis and surgery was 17 days (range, 2–30 days), while in group 2, it was 38 days (range, 31–94 days). Group 1 experienced a delay of 7 days (range, 0–29 days) from USG to surgery at Asan Medical Center, while group 2 experienced a delay of 18 days (range, 0–72 days). The follow-up period after surgery was 71 months (range, 6–78 months) in group 1 and 72 months (range, 4–80 months) in group 2. During postoperative follow-up, 77 patients (8.5%) in group 1 experienced disease recurrence and 35 patients died (3.9%), while in group 2, 19 patients (11.4%) experienced disease recurrence and four patients (2.4%) died (Table 2).
Regarding comparison between the tumor size identified on USG with biopsy for pathological diagnosis and the tumor size identified based on pathological results after surgery, there were no significant differences between the two groups (p=0.134). Among group 1,704 patients (77.6%) experienced a change in tumor size of more than 0.5 cm; 101 patients (11.2%) experienced a change in size between 0.6 cm and 1.0 cm; 69 patients (7.6%) experienced a change in size between 1.0 cm and 2.0 cm; and 33 patients (3.6%) experienced a change in size of more than 2.0 cm. Among group 2, the corresponding numbers of patients experiencing changes in tumor size were, respectively, 116 patients (69.6%), 25 patients (14.6%), 15 patients (9.1%), and 11 patients (6.7%). A comparison between preoperative tumor size determined by USG conducted at Asan Medical Center and tumor size based on postoperative pathological results also showed no significant difference between the two groups (p=0.249). In addition, there was no significant difference between the two groups (p=0.233) regarding the USG results observed at Asan Medical Center and changes of metastatic lymph node status based on pathological results after surgery. According to these results, when comparing disease progression in patients whose operation was delayed for more than 30 days after diagnosis with that in those whose operation was performed within 30 days after diagnosis, there were no important distinctions between the two groups in terms of tumor size change or lymph node metastasis (Table 3).
During the median follow-up period (71 months for group 1 and 72 months for group 2), no significant statistical difference was found between the two groups with respect to DFS (p=0.395) or OS (p=0.813) (Figure 2).

DISCUSSION

In the diagnosis of breast cancer and surgery, there are cases in which an operation is delayed owing to a variety of patient, provider, and health care system factors [2]. Patients might visit several hospitals to receive second opinions from other doctors after a diagnosis of breast cancer, or make a delayed appointment for surgery because of other personal matters. By performing USG, biopsies, and other procedures to clarify breast cancer diagnoses, providers may cause surgical delays. Other times, surgeries might be delayed owing to health care system factors caused by limitations in labor, equipment, or operating room availability. For instance, biopsies that must be executed for diagnoses might not be performed immediately after ambulatory care, or there may be a shortage of operating doctors or a long waiting list for available operation dates, which might pose an obstacle to the rapid progression of medical service.
Two previous studies were conducted in South Korea. In the first study, patients who experienced surgical delays of more than 30 days showed worse survival rates compared to those who underwent surgery within 30 days after the initial diagnosis [2]. Similarly, in the second study, patients who underwent delayed surgery (after more than 12 weeks) showed worse survival rates compared to those who underwent surgery within 12 weeks after the initial diagnosis [4].
Similarly, in the United States, a recent retrospective study on young patients with breast cancer, aged 15 to 39 years, reported that the 5-year survival rate worsened when the delay in treatment time was over 6 weeks [5]. However, because the above-mentioned studies were performed based on patient information from government databases, it might be necessary to review the accuracy of the databases and results. These studies included no analyses of the clinical characteristics of patient groups and, furthermore, they were heterogeneous in diagnostic methods and operational methods. Thus, there might be biases in judging the effects of surgical treatment delays on prognoses. In contrast to previous studies, the present study analyzed a database of patients with breast cancer surgery executed solely at our hospital. The current study separated the time of delay from diagnosis until surgery into periods of >30 days and ≤30 days, and compared the two groups; the results of this analysis showed that the prognosis of patients whose time delay was >30 days was not significantly different from that of those whose time delay was ≤30 days. Also unlike previous studies, to achieve greater reliability, the present study conducted analyses based on a large-volume database from a single institution, and evaluated diagnostic and surgical methods as well as pathological analyses performed within our own well-developed oncology hospital. Furthermore, this study was able to increase the accuracy of diagnoses prior to surgery by allowing only specialized radiologists for breast cancer to perform USG on all patients before surgery. It also limited the surgical method to two types: BCS or mastectomy, and included only stage I to III patients to limit biases affecting results. Lastly, it heightened the reliability of results in that pathological results were also obtained within this single institution. Moreover, the present study distinguishes itself from others in that it analyzed tumor progression such as changes in tumor size and lymph node metastasis as well as survival outcomes. This study compared initial tumor sizes during USG performed at the time of diagnosis and subsequent tumor sizes on postoperative pathological reports. Comparison between tumor size observed on initial USG performed preoperatively at Asan Medical Center and tumor size observed postoperatively showed no significant differences between the two groups when delay times from diagnosis until surgery were divided on the basis of ≤30 days or >30 days. Additionally, comparative results of axillary lymph nodes metastases identified from the results of USG performed at Asan Medical Center again showed no significant differences between the two groups. These findings contrast with those of previous studies that stated that increased waiting times between initial diagnosis and surgery correlated with increased tumor sizes and progression of lymph node metastases, yielding poor prognoses. The reason that the present study obtained a different outcome from others is that this study limited biases as much as possible. The present study not only simplified diagnostic and surgical methods but also increased the consistency of results by allowing the performance of preoperative USG and postoperative pathologic diagnoses within a single institution. In terms of DFS or OS rates, it was revealed that prognoses between the two groups were similar, owing to the observation of no significant differences between the two groups. Among data in the present study, with the exception of case 11, in which the waiting period was longer than 60 days, no significant differences were found between the two groups. In a study that compared delay times from initial diagnosis until surgery on the shorter basis of ≤15 days or >15 days, the gap between the two groups was found to be even further decreased. In that study, DFS and OS rates were also compared between group 1 and group 2 for patient age (age <35 years or ≥35 years), histologic grade (HG 1–2, HG 3), tumor stages (I, II, and III), and each tumor subtype. However, these data similarly showed no significant differences (data not shown).
As shown in Table 1, surgical method, postoperative chemotherapy, and radiotherapy demonstrated significant differences between the two groups. Group 2 had a higher proportion of patients who underwent mastectomy, and most of these patients received reconstructive surgery at the same time (group 1, 17.3% vs. group 2, 60.5%). These immediate reconstructive surgeries following mastectomy sometimes led to scheduling problems, which may also lengthen the waiting time for surgery. Because the proportion of patients who underwent BCS in group 1 was greater than that in group 2, postoperative radiotherapy was more often performed in group 1 (74.0% vs 58.1%, p<0.001). Postoperative chemotherapy was also more often performed in group 1 (68.0% vs. 58.1%, p=0.012). While the findings are difficult to explain, the proportions of ER-negative, PR-negative, triple-negative subtype, histologic grade 3, and pathologic tumor size (2–5 cm) were all higher in group 1. It is hypothesized that these chemotherapy-related factors could be associated with the higher proportions of postoperative chemotherapy in group 1.
The U.K. government introduced the “Cancer waiting time targets” in the year 2000 and recommended that the overall time from referral of the patient with suspected cancer to diagnosis and the initiation of treatment should not exceed 62 days. However, the association between these waiting time targets and prognosis might differ according to cancer type [11,12].
Certainly, a multidisciplinary approach is recommended for effective breast cancer treatment, and if patients would be able to receive sufficient time for evaluation regarding appropriate curative surgery, they could receive more positive treatment effects, even though this might require longer waiting times (up to 2 months) from diagnosis until surgery. This outcome of being able to wait longer without adverse effects could be helpful in reducing the severe anxiety experienced by some patients who might suffer from worry regarding prolonging the initiation of surgical processes after having received diagnoses of breast cancer.
This study does have some limitations. First, this survey was retrospectively performed at a single institution, and it was not a multicenter study. Because of differences in each institution’s preoperative evaluation policy, there is risk in generalizing the results of this study. In 2008, when the patients in this study were evaluated, routine preoperative evaluations for breast cancer patients in Asan Medical Center were mammography and USG, and more complex examinations such as computed tomography, magnetic resonance imaging, or positron emission tomography were not routinely performed. Secondly, the present study did not analyze the effect caused by surgical treatment delays of more than 60 days, because there were only 11 such cases. Thirdly, because we retrospectively collected each patient’s clinical data, we might be unable to control bias regarding clinical results. Fourthly, we compared the preoperative tumor size based on USG with the postoperative pathologic size to compare postsurgical changes in tumor size owing to surgical delay. We agree that this method is not objective and there may be discrepancies in the tumor size because of changes in the method of measurement. Because we did not perform additional USG before surgery, comparison of the tumor size with USG was not possible. In addition, as we did not routinely perform axillary lymph node biopsy (fine-needle aspiration or core needle biopsy) in all patients, we had to compare the node status with clinical USG findings and pathologic findings for this report. To strengthen its contentions, findings, and implications for future patients with breast cancer, the results of the present study need to be compared to the results of previous studies and also further investigated through a long-term follow-up study involving a large number of patients to validate these data and findings.
In conclusion, the present study found that among patients divided into two groups consisting of those undergoing surgery before 30 days and after 30 days from diagnosis of invasive breast cancer to surgery, comparison of data revealed no important differences in change of tumor size or change of metastatic lymph node status between the two groups. Furthermore, no significant gap for either DFS or OS rate was found between the two groups. Consequently, the results from this study have shown that during a comparatively short period of 2 months after the diagnosis of breast cancer, such delays in surgery did not adversely affect cancer progression and respective survival rates. Nonetheless, this argument still needs to be proven through a larger-scale, long-term study based on a larger patient sample size in the future.

CONFLICT OF INTEREST

The authors declare that they have no competing interests.

Figure 1.
Study inclusion and exclusion criteria.
BCS=breast-conserving surgery. *Patients #1, #2: received long-term traditional therapy after diagnostic biopsy. Patients #3, #4: received BCS on the same day biopsy was performed. Patients #5, #6: no ultrasonography imaging was performed at the time of fine-needle aspiration biopsy.
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Figure 2.
Comparison of survival outcomes between two groups (delay in surgery ≤30 days vs. delay in surgery >30 days).
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Table 1.
Clinicopathological characteristics of patients
Characteristic Group 1* (n = 907) Group 2 (n = 167) p-value Characteristic Group 1* (n = 907) Group 2 (n = 167) p-value
No. (%) No. (%) No. (%) No. (%)
Age (yr) 0.211 No. of lymph node metastasis 0.680
 < 35 43 (4.7) 13 (7.8)  0 560 (61.7) 101 (60.5)
 35–50 513 (56.6) 96 (57.5)  1–3 239 (26.4) 48 (28.7)
 > 50 351 (38.7) 58 (34.7)  4–9 64 (7.1) 13 (7.8)
Stage 0.356  ≥ 10 44 (4.8) 5 (3.0)
 I 389 (42.9) 74 (44.3) Subtypes 0.286
 II 401 (44.2) 71 (42.5)  ER (+) or PR (+) / HER2 (–) 481 (56.9) 85 (60.7)
 III 117 (12.9) 22 (13.2)  ER (+) or PR (+) / HER2 (+) 89 (10.5) 19 (13.6)
ER 0.561  ER (–) / PR (–) / HER2 (+) 102 (12.1) 16 (11.4)
 Positive 578 (63.9) 112 (67.1)  ER (–) / PR (–) / HER2 (–) 174 (20.6) 20 (14.3)
 Negative 326 (36.1) 55 (32.9)  Unknown 61 27
 Unknown 3 0 Operation method < 0.001
PR 0.276  BCS 613 (67.6) 81 (48.5)
 Positive 504 (55.8) 103 (61.7)  Mastectomy 294 (32.4) 86 (51.5)
 Negative 400 (44.2) 64 (38.3) Postoperative treatment
 Unknown 3 0  Chemotherapy 0.012
HER2 0.527   Yes 617 (68.0) 97 (58.1)
 Negative 655 (77.4) 105 (75.0)   No 290 (32.0) 70 (41.9)
 Positive 191 (22.6) 35 (25.0)  Radiotherapy < 0.001
 Unknown 61 27   Yes 671 (74.0) 97 (58.1)
Histologic grade 0.430   No 236 (26.0) 70 (41.9)
 1&2 566 (62.9) 113 (68.1)  Endocrine therapy 0.105
 3 334 (37.1) 53 (31.9)   Yes 645 (71.1) 129 (77.2)
 Unknown 7 1   No 262 (28.9) 38 (22.8)
Pathological tumor size (cm) 0.320 Diagnosis method 0.955
 ≤2 528 (58.2) 104 (62.3)  CNB 880 (97.0) 163 (97.6)
 2–5 353 (38.9) 56 (33.5)  FNA 27 (3.0) 4 (2.4)
 >5 26 (2.9) 7 (4.2)

ER=estrogen receptor; PR=progesterone receptor; HER2=human epidermal growth factor receptor 2; BCS=breast-conserving surgery; CNB=core needle biopsy; FNA=fine needle aspiration.

* Delay in surgery ≤30 days;

Delay in surgery >30 days.

Table 2.
Comparison of time duration from diagnosis to surgery and follow-up status between two groups
Variable Group 1* (n = 907) Group 2 (n = 167)
Age at surgery (yr) 48 (24–82) 47 (22–85)
Duration (day)
 Between diagnosis (biopsy) and surgery 17 (2–30) 38 (31–94)
 Between USG at Asan Medical Center and surgery 7 (0–29) 18 (0–72)
Follow-up (mo) 71 (6–78) 72 (4–80)
Follow-up state
 NED 779 (85.9) 140 (83.8)
 Recurrence 77 (8.5) 19 (11.4)
 Dead 35 (3.9) 4 (2.4)
 Missed 16 (1.7) 4 (2.4)

Data are presented as median (range) or number (%).

USG=ultrasonography; NED=no evidence of disease.

* Delay in surgery ≤30 days;

Delay in surgery >30 days.

Table 3.
Changes in tumor size and lymph node status during delays from diagnosis to surgery between two groups
Group 1* (n=907) Group 2 (n=167) p-value
No. (%) No. (%)
Tumor size change
 Between USG at diagnosis and surgery (cm) (n = 1,074) 0.134
  ≤ 0.5 704 (77.6) 116 (69.6)
  0.6–1.0 101 (11.2) 25 (14.6)
  1.0–2.0 69 (7.6) 15 (9.1)
  > 2.0 33 (3.6) 11 (6.7)
 Between USG at Asan Medical Center and surgery (cm) (n = 1,073) 0.249
  ≤ 0.5 763 (84.2) 134 (80.2)
  0.6–1.0 48 (5.3) 11 (6.6)
  1.0–2.0 51 (5.6) 8 (4.8)
  > 2.0 44 (4.9) 14 (8.4)
Lymph node status change between USG at Asan Medical Center and surgery (n = 999) 0.233
 USG finding→pathologic result
  No metastasis or suspicious metastasis→no metastasis 516 (62.0) 88 (59.9)
  No metastasis→metastasis 117 (14.1) 27 (18.3)
  Suspicious metastasis→metastasis 199 (23.9) 32 (21.8)

USG=ultrasonography.

* Delay in surgery ≤30 days;

Delay in surgery >30 days.

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