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Health services research and breast cancer

Health services research tends to have an unglamorous image; some people are not even sure what its objectives are, what it does, or whether it provides value for money. It is therefore notable that a comment in a recent BMJ is entitled "miraculous developments from health services research" . The piece should be of particular interest to our readers since it concerns breast cancer care.

Specialist centres do better

The comments are based on the findings of a study of survival outcomes of 3786 breast cancer patients treated in the west of Scotland between Jan 1980 and June 1988 and followed to the end of 1993 [1]. The five year survival rate was 9% higher and the 10 year rate 8% higher for patients treated by specialist surgeons compared with those treated by general surgeons. When appropriate adjustments were made to standardise the results the reduction in the risk of dying looked even better at 16%. The benefits of specialist care were found across all sub-groups examined, such as different ages of patients, different sizes and stages of tumours, and patients from different socio-economic backgrounds.

Design

The study was conducted in a defined population of 1.5 million people in the west of Scotland, with 98% of all known cases of histologically verified cases of breast cancer being included during the years 1980-1988. Some 918 patients were treated by surgeons with a special interest in breast cancer, compared with 2868 patients treated by surgeons with no special interest. Most patients (89%) were treated at their local hospital.

For the purposes of this study, surgeons with a special interest in breast cancer were defined as setting up a dedicated breast clinic, a defined association with pathologists and oncologists, organising and facilitating clinical trials and maintaining a separate record of all patients with breast cancer in their care.

Comment

The message is a clear one and confirms what a number of leading oncologists have been saying for some considerable time now, namely that the survival of patients with breast cancer is better when they are treated by surgeons with a special interest in breast cancer rather than by general surgeons. It is a case where, as with hip fractures [2], an overall package of care may prove to be more important than any particular item of the package.

Such significant differences have implications for the provision of services for the treatment of women with breast cancer and almost certainly for patients with many other types of cancer. There is an urgent need to achieve equity in cancer treatments. The proposals for a network of Cancer Centres and Cancer Units set out in the report of the advisory group convened by the Chief Medical Officer, Dr (now Sir) Kenneth Calman; "A Policy Framework for Commissioning Cancer Services" would at least provide the infrastructure on which such a service could be achieved.

References:

  1. CR Gillis, DJ Hole. Survival outcome of care by specialist surgeons in breast cancer: a study of 3786 patients in the west of Scotland. British Medical Journal 1996 312: 145-8.
  2. CJ Todd, CJ Freeman, C Camelleri-Ferrante et al. Differences in mortality after fracture of the hip: the East Anglian audit. British Medical Journal 1995 310: 904-8.



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