Breast cancer management: is volume related to quality?

Abstract

Summary A method of carrying out region-wide audit for breast cancer was developed by collaboration between the cancer registry, providers and purchasers as part of work to fulfill the 'Calman-Hine' recommendations. In order to test the audit method, a retrospective audit in North Thames East compared practice in 1992 against current guidelines. The analysis compared care in specialist and non-specialist centres. A stratified random sample comprising 28% of all breast cancer patients diagnosed in 1992 was selected from the population-based Thames Cancer Registry. The data for 309 patients with stage I-Ill tumours were analysed by hospital type using local guidelines. No difference between specialist (high volume) and non-specialist centres was detected for factors important in survival. Pathological staging was good with over 70% reporting tumour size and grade. A small number of patients were undertreated; after conservative surgery, 10% (19) of women did not receive radiotherapy, and 15% (8) of node-positive premenopausal women did not receive chemotherapy or ovarian ablation. In contrast, a significant trend with hospital volume was found for several quality of life factors. These included access to a specialist breast surgeon and specialist breast nurses, availability of fine-needle aspiration (FNA), which ranged from 84% in high-volume to 42% in low-volume centres, and quality of surgery (axillary clearance rates ranged from 51% to 8% and sampling of less than three nodes from 3% to 25% for high-and very low-volume centres respectively). Confidential feedback of results to surgeons was welcomed and initiated change. The summary information gave purchasers information relevant to the evaluation of cancer services. While the audit applied present standards to past practice, it provided the impetus for prospective audit of current practice (now being implemented in North Thames).

An audit of breast cancer pathology reporting in Australia in 1995

“…A similar trend was found in the 1992 audit in NSW in which reporting was more complete from pathologists who issued at least 2-3 reports a month or were based in teaching hospitals (Bilous et al, 1995). Volume of institutional reporting in the UK was also associated with item completeness, although inconsistently since reporting of tumour size fell as volume increased while margins of excision and histological grade were more completely reported as volume increased (Ma et al, 1997).…”

“…Pathology reports of invasive breast cancers in 1995 in Australia had higher levels of information of size (complete for 94% of women) and histological grade (84%) than a UK health region in 1992 (size and grade each 74% complete; Ma et al, 1997). The UK study, on the other hand, had more complete information (94%) on surgical margins of excision than in Australia (84%; Ma et al, 1997).…”

“…The UK study, on the other hand, had more complete information (94%) on surgical margins of excision than in Australia (84%; Ma et al, 1997).…”

Early-stage breast cancer

“…Many studies support the notion that a large hospital caseload is associated with the adoption of therapeutic innovations and discourages inappropriate interventions; 5,8,12,16,17,[19][20][21][22] not all studies support this notion, however. 7,11,14,18,29,37 The strong attenuation of most effects observed in this study after adjusting for potential confounding variables highlights both the relation between caseload and other hospital-and physician-related variables and the need for appropriate analytic strategies.…”

“…Hospital characteristics that have been reported to significantly affect treatment and outcomes include the teaching status [1][2][3][4][5][6][7][8][9][10][11] and location 1,8,[12][13][14][15] of the hospital, patient volume, 5,7,8,12,14,[16][17][18][19][20][21][22] and the onsite availability of specialized services needed for treatment. 1,7,10,20,23,24 In addition, more favourable outcomes have been demonstrated among women treated by physicians who have larger caseloads or more experience with patients with breast cancer.…”