Why does specialist treatment of breast cancer improve survival? The role of surgical management

Abstract

Evidence that the survival of women with breast cancer treated by specialist surgeons is better than that by nonspecialists is limited. Previous reports have not identified the cause of this survival advantage. Our aim was to determine if the survival difference was due to case-mix, adjuvant treatment or the treatment provided by specialist surgeons. The case-records and pathology reports of 2776 women were reviewed. This represented 95% of all those diagnosed with breast cancer between 1/1/1986 and 31/12/1991 in a defined geographical area. Case-mix, surgery, pathology and adjuvant therapies of the 2148 women treated with curative intent were analysed. A standard of adequate surgical management was defined and confirmed as a valid predictor by examining rates of local recurrence, independent of all other prognostic factors. Against this standard, we compared the adequacy of surgical management, local recurrence rates and the survival outcomes of specialists and nonspecialists over an 8-year follow-up period. The interrelationship between adequacy of surgical management, locoregional recurrence and survival was examined. While the case-mix and prescription of adjuvant therapies were comparable between specialist and nonspecialist surgeons, the efficacy and outcome of local treatment differed widely. Breast cancer patients treated in specialist compared to nonspecialist units had half the risk of inadequate treatment of the breast (24 vs 47%, Po0.001), a five-fold lower risk of inadequate axillary staging (8 vs 40%, Po0.001) and nine times lower risk of inadequate definitive axillary treatment (4 vs 38%, Po0.001). Local recurrence rates were 57% lower (13 vs 23% at eight years, Po0.001) and the risk of death from breast cancer was 20% lower for women treated in specialist units, after allowing for casemix and adjuvant therapies. Adequacy of surgical management correlated with locoregional recurrence, which in turn correlated with the risk of death. The surgical management in specialised breast units is more often adequate, local and regional recurrence rates are lower, and survival is correspondingly better. We conclude that adequate surgical management of breast cancer is fundamental to improving the outcome from breast cancer irrespective of where it is delivered.

Investigating the correlation between hospital of primary treatment and the survival of women with breast cancer

“…[1][2][3][4][5][6][7][8][9][10][11][12][13][14][15] Two recent reviews 16,17 suggested that volume is a key determinant of performance. This association has been documented for several health conditions, but not for all, 18,19 and the underlying mechanisms are likely disease-specific.…”

Social and geographic disparities in access to reference care site for patients with colorectal cancer in France

“…Several studies suggest that differences in access to a specialised care centre are likely to contribute towards such a disparity. In Scotland, two studies (Pitchforth et al, 2002;Kingsmore et al, 2004) have evidenced that patients treated in a nonspecialist cancer unit were not given the same treatment as those treated in a specialist cancer unit, for colorectal cancer and breast cancer, respectively. Two other recent studies (Smith et al, 2003;McArdle and Hole, 2004) confirmed that colorectal cancer patients had a better survival rate when managed by specialised surgeons.…”

Fylkesvise forskjeller i overlevelse av brystkreft

“…Andre studier har vist sammenheng mellom kirurgvolum og dødelighet ved avanserte kirurgiske inngrep (21,22). Dette kan også vaere tilfelle for kirurgisk behandling av brystkreft (23)(24)(25)(26)(27). Man diskuterer om den økte overlevelsen kan forklares gjennom bedret kirurgi eller om det er den enkelte brystkreftkirurgen som i større grad henviser til høyspesialiserte brystonkologer (28,29).…”

“…For å studere denne sammenhengen må vi ha sikrere data på at anbefalt behandling virkelig er blitt gitt. Trolig må vi også studere den enkelte behandler og hans eller hennes prestasjoner (21,(22)(23)(24)(25)(26)(27). I hvilken grad mammografiscreening og forbedret behandling innvirker på de fylkesvise forskjellene i overlevelse, kan man ikke si uten å ha fått informasjon om brystkreftsvulsten er oppdaget ved screeningmammografi eller ved mammografi utført på bakgrunn av pasientens symptomer.…”