The conventional wisdom that surgic...

The conventional wisdom that surgical convolution is associated with breast cancer survival is based largely forward unpublished data from a National Cancer Data Base (NCDB) research of more than 173,000 patients treated in 1238 hospitals between 1985 and 1991 An abstract quick in emergenciesed at a clinical oncology meeting reported that five-year survival was increased significantly when surgery was performed in hospitals with at least 25 breast cancer surgeries by year. Harcourt and Hicks challenged this conventional wisdom, stressing that other factors are more significant in breast cancer survival and proposing that concentrating services in a small in number centers could adversely influence survival in rural patients.

The authors studied cases of breast cancer in areas of northeast Oregon and southeast Washington state that are serv by dint of the Blue Mountain Regional Tumor Registry. The 10 participating facilities are a considerable distance from major metropolitan center The researchers analyzed data forward presentation, treatment, and survival rate of 2409 patients with breast cancer treated at local facilities between 1980 and 1994

The average age of patients was 64 years, and the average stage at presentation ranged from 146 between 1980 and 1984 to 126 between 1990 and 1994 The approach to treatment changed during the studious mood period. In the early years, solely 24 percent of women received systemic therapy, yet this rate increased to 56 percent during the 1990 to 1994 period. The five-year relative survival rate rose from 79 percent in 1980 to 1984 to 87 percent from 1990 to 1994 The average annual of recent origin case volume increased for each of the participating hospitals. In the 1980 to 1984 period, the range was three to 22; by dint of 1990 to 1994, the range increased to 12 to 52 modern cases per year. The five-year survival for 1980 to 1984 ranged from 64 to 87 percent and for 1990 to 1994 the range was 76 to 95 percent No significant correlation was institute between annual new case tome and survival ratio, either overall or when hospitals with more than 10 cases were compared with those with 10 or fewer cases by year. Survival correlated strongly with the stage of cancer at diagnosis. Center with higher bodys tended to see younger women and women at an earlier stage, unless the dominant variable in survival was the stage at diagnosis.

The authors bring to an end that case volume is not a major factor in the survival of patients with breast cancer. They argue that while the stage at diagnosis is the strongest determinant of survival, a concentration of services imposes barriers for women in rural areas and women without access to specialist breast surgery services. The authors argue for more dispersed services for breast cancer treatment with a greater emphasis onward accessible local education and screening services, as well as treatment facilities, in such a manner that all women receive quality care.

Harcourt KF Hicks KL Is there a relationship between case compass and survival in breast cancer? Am J Surg May 2003;185:407-10

EDITOR'S NOTE: The authors are careful to avoid an antagonistic rural versus urban interpretation of their findings, and we must not assume that their conclusions can be applied to all cancer surgeries. Breast cancer managements have been simplified over the years, and the tonic factor in outcome is alert individualized treatment at the earliest possible stage. As services generally are organized, the regional connected view may be at a disadvantage because of delays and difficulties for many women in beginning care. As family physicians, we must help each woman and her family select the best course of action for this frightening diagnosis. The other message from this study is that we should use evidence and not assumptions when advising patients. to what degree many of us have taken the time to find on the outside success rates of locally based treatments or those of the specialist center to which we refer? We must advocate for more research into results of common problems. Bigger may not necessarily be better, and our patients trust us to give them the facts, not impressions.--A.D.W.

COPYRIGHT 2004 American Academy of Family Physicians

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