Longer Waits for Breast Cancer Surgery Fuel Worry About the Future, Swedish Study Finds

For a woman newly diagnosed with breast cancer, the weeks between hearing the word cancer and lying on an operating table can feel like the longest of her life. A new study from Sweden now offers the most rigorous population-level evidence yet that this waiting period is not just emotionally fraught in a general sense, but that longer waits specifically amplify a very particular kind of psychological burden: worry about one’s future health. The findings, published in Breast Cancer Research and Treatment, suggest that the clock ticking toward surgery measures more than logistics; it may shape how patients mentally confront their disease.

Researchers led by Johan Eriksson of Umeå University drew on the Swedish National Quality Register for Breast Cancer, a population-based database with near-complete coverage of breast cancer cases in the country. They identified 2,906 women with primary invasive breast cancer who underwent breast surgery between January 2020 and December 2024 and who had completed patient-reported outcome measures, or PROMs, at baseline. Most of the women also completed follow-up questionnaires at six and twelve months, giving the team a longitudinal view of psychological wellbeing rather than a single snapshot. This is, according to the authors, the first national registry-based longitudinal study to connect surgical lead time with disease-specific patient-reported worry.

The exposure at the heart of the study was deceptively simple: the number of calendar days between the diagnostic biopsy and the primary breast operation. The median lead time was 32 days, with an interquartile range of 23 to 42 days, and 61.6 percent of patients were operated on within 35 days. Importantly, the researchers standardized the lead time as a z-score, so each statistical step corresponded to roughly 19 additional days of waiting. This allowed them to model waiting time as a continuous variable across the entire distribution rather than arbitrarily dividing patients at a policy threshold.

The primary outcome was a single, carefully chosen item from the EORTC QLQ-BR23 quality-of-life instrument: were you worried about your health in the future during the past week? Patients answered on a four-point scale from not at all to very much, and those responding quite a lot or very much were classified as experiencing high future-health worry. Secondary outcomes included general worry, tension, depressed mood, and overall quality of life from the companion EORTC QLQ-C30 questionnaire. The statistical machinery consisted of mixed-effects cumulative link models, which handle ordinal outcomes and account for repeated measures within each patient and for clustering across Sweden’s healthcare regions.

The result was clear and consistent. Each additional standard deviation of waiting time, about 19 days, was associated with 15 percent higher odds of reporting greater worry about future health, with a confidence interval of 1.04 to 1.27. Because the study period coincided with the COVID-19 pandemic, the team tested whether calendar-time trends could explain the association. They were not fully explained: the estimate shifted only modestly, from 1.17 without calendar-time adjustment to 1.15 with a pandemic-era indicator and 1.13 with diagnosis year as a categorical variable, with the confidence interval remaining above unity in every specification. A sensitivity analysis restricted to waits of 90 days or less, arguably the clinically most relevant range, produced an even slightly stronger association of 1.18.

The descriptive contrast at baseline makes the pattern tangible. Among women whose lead times exceeded 35 days, 42.2 percent reported substantial worry about their future health, compared with 35.1 percent of those operated within 35 days, an absolute difference of 7.1 percentage points. The gap appeared across all tumour-size subgroups and was largest for cT2 tumours, where the figures were 48.6 percent versus 37.2 percent. While such a difference may seem modest for any individual patient, at the population scale of a country where thousands of women undergo breast cancer surgery each year, the authors argue it could be meaningful.

Perhaps most intriguing is the selectivity of the effect. General worry, tension, depressed mood, and overall quality of life all showed smaller, non-significant associations with lead time, with odds ratios clustered around 1.04 to 1.07. Rates of high tension and depressed mood were nearly identical regardless of whether women waited more or less than 35 days. This divergence suggests that longer waits may not uniformly crank up psychological distress; instead, they may trigger a specific future-oriented cognitive response in which patients reason about what a longer timeline might imply for their prognosis. The authors connect this to established models of cancer-related anxiety and to the concept of fear of cancer recurrence, a construct known to be particularly responsive to prognostic uncertainty and cancer-related cues. Prior evidence from pandemic-era treatment delays, which found links between delay experiences and recurrence-related worry, fits the same picture.

The study’s technical care extends to linearity checks. Categorical estimates across lead-time bands of up to 14, 15 to 21, 22 to 30, 31 to 45, and over 45 days rose across the lower categories and then plateaued, though overlapping confidence intervals prevented identification of a discrete threshold. A generalized additive model with a cubic regression spline produced an effective degrees of freedom of 1.67 and a fit essentially identical to the linear specification, supporting the continuous treatment of waiting time. Notably, a binary 35-day threshold model failed to converge due to a singular variance-covariance matrix, so inference about the Swedish policy cut-off rests on descriptive contrasts rather than a model-based odds ratio.

Context matters here. Breast cancer is the most common malignancy among Swedish women, with 8,803 new cases and 1,328 deaths registered in 2024. Surgery within the standardized care pathway target has proved stubbornly difficult to achieve: the target was extended from 28 to 35 days in January 2024 to reflect changes in diagnostic practice, including the shift from fine-needle cytology to core needle biopsy and more frequent preoperative MRI, yet only 47 percent of patients met the revised target in 2024. Median lead time in the study cohort rose from 25 days in 2020 to 34.5 days in 2024, and the share operated within 35 days fell from 78.1 percent to 54.8 percent, with striking regional variation from 77.6 percent in Region North to 56.8 percent in Region South. The authors caution that longer waits do not always signal inferior care, since they can reflect more thorough preoperative work-up.

Limitations temper the conclusions. The observational design cannot establish causation, and residual confounding remains possible: patients with more complex disease may both wait longer and worry more. PROM participation was non-random, with baseline coverage rising from roughly 5 percent of invasive cases in 2020 to 13 percent in 2024, so selection into the cohort cannot be excluded. The study also could not account for subsequent chemotherapy, endocrine therapy, or radiotherapy, which may influence worry at later follow-ups, and baseline questionnaires could not be precisely dated relative to the waiting interval. Even so, the authors conclude that the preoperative waiting period is a promising context for improved communication, including clear information about expected timelines and the reasons for any delay. In an era when cancer care is increasingly measured in survival statistics, this study is a reminder that the days between diagnosis and surgery carry their own measurable weight, and that how clinicians explain the wait may matter almost as much as the wait itself.

Subject of Research: The association between breast cancer diagnosis-to-surgery lead time and patient-reported worry about future health

Article Title: Diagnosis-to-surgery lead time and future-health worry in women with primary breast cancer: a longitudinal Swedish registry-based cohort study

Article References: Eriksson, J., Fredriksson, I., Lindholm, L., Appelblad, M., & Sund, M. (2026). Diagnosis-to-surgery lead time and future-health worry in women with primary breast cancer: a longitudinal Swedish registry-based cohort study. Breast Cancer Research and Treatment, 220(1), Article 3. https://doi.org/10.1007/s10549-026-08107-z

Image Credits: AI Generated

DOI: 10.1007/s10549-026-08107-z

Keywords: breast cancer, lead time, surgery, patient-reported outcomes, psychological distress, fear of cancer recurrence, Sweden, quality register, EORTC QLQ-BR23, healthcare pathways, waiting time, oncology