Does High Surgeon and Hospital Surgical Volume Raise the Five-Year Survival Rate for Breast Cancer? A Population-Based Study
Department of Economics, National Taipei University, Taipei, Taiwan. Breast Cancer Research and Treatment
(Impact Factor: 3.94).
07/2008; 110(2):349-56. DOI: 10.1007/s10549-007-9715-4
This study sets out to examine the relationship between both surgeon and hospital volume and five-year survival rates for breast cancer patients. We performed Cox proportional hazard regressions on a pooled population-based database linking the Taiwan National Health Insurance Research Database with the 'cause of death' data file, covering the three-year period from January 1997 to December 1999. Of the 13,360 breast cancer resection patients in our study sample, the five-year survival rates, by surgeon volume, were 77.3% in the high-volume group (>201 cases), 76.9% in the medium-volume group (45-200), and 69.5% in the low-volume group (<or=44). The five-year survival rates, by hospital volume, were 77.3% for high-volume hospitals (>585 cases), 74.5% for medium-volume hospitals (259-585) and 72.1% for low-volume hospitals (<or=258). Cox regression analyses show that the risk of death for patients treated by low-volume surgeons was up to 1.305 times (P < 0.001) as high as the risk for those treated by high-volume surgeons. Similarly, the risk of death for patients whose resections had been performed in low-volume hospitals was 1.484 times (P < 0.001) as high as the risk for those whose resections had been performed in high-volume hospitals. High surgeon or hospital volume contributes significantly to patient outcomes and may be regarded as an overall indicator of high treatment quality; we therefore strongly recommend that the healthcare authorities reveal to the public all of the relevant information on provider performance and caseloads in order to assist them to make the optimum choice when surgery becomes necessary.
Available from: Julie Gentil
- "As shown in many studies, being treated in a specialized medical centre or by a high-volume surgeon is an independent prognostic factor for survival in patients with cancer, breast cancer particularly [1-9]. Moreover it is now well known that the socio-economic level is also an independent factor of survival in women with breast cancer [10-13]. "
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ABSTRACT: It has been shown in several studies that survival in cancer patients who were operated on by a high-volume surgeon was better. Why then do all patients not benefit from treatment by these experienced surgeons? The aim of our work was to study the hypothesis that in breast cancer, geographical isolation and the socio-economic level have an impact on the likelihood of being treated by a specialized breast-cancer surgeon.
All cases of primary invasive breast cancer diagnosed in the Côte d'Or from 1998 to 2008 were included. Individual clinical data and distance to the nearest reference care centre were collected. The Townsend Index of each residence area was calculated. A Log Rank test and a Cox model were used for survival analysis, and a multilevel logistic regression model was used to determine predictive factors of being treated or not by a specialized breast cancer surgeon.
Among our 3928 patients, the ten-year survival of the 2931 (74.6 %) patients operated on by a high-volume breast cancer surgeon was significantly better (LogRank p < 0.001), independently of age at diagnosis, the presence of at least one comorbidity, circumstances of diagnosis (screening or not) and TNM status (Cox HR = 0.81 [0.67-0.98]; p = 0.027). In multivariate logistic regression analysis, patients who lived 20 to 35 minutes, and more than 35 minutes away from the nearest reference care centre were less likely to be operated on by a specialized surgeon than were patients living less than 10 minutes away (OR = 0.56 [0.43; 0.73] and 0.38 [0.29; 0.50], respectively). This was also the case for patients living in rural areas compared with those living in urban areas (OR = 0.68 [0.53; 0.87]), and for patients living in the two most deprived areas (OR = 0.69 [0.48; 0.97] and 0.61 [0.44; 0.85] respectively) compared with those who lived in the most affluent area.
A disadvantageous socio-economic environment, a rural lifestyle and living far from large specialized treatment centres were significant independent predictors of not gaining access to surgeons specialized in breast cancer. Not being treated by a specialist surgeon implies a less favourable outcome in terms of survival.
Available from: Cristiane Murta-Nascimento
- "Differences in the stage distribution according to route to diagnosis were taken into account in multivariate analyses. Several studies observed a prognostic value of surgeon's experience in breast cancer survival [12,25,26], while others found no effect . In our case, we did not observe a significant effect in the multivariate analysis, which could be due to several circumstances. "
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Data from a long-established hospital-based cancer registry were used to analyse the relationship between clinical and organisational factors and disease-specific survival among women with primary breast cancer.
2023 women with incident invasive breast cancer diagnosed from 1992 to 2005 were identified through the Hospital del Mar Cancer Registry (Barcelona, Spain). Patients were followed until December 2008. One-, 5- and 10-year disease-specific survival rates were estimated. Kaplan-Meier and Cox regression models were used to analyse death from breast cancer.
At diagnosis 70.2% of tumours were in stages I-II. During follow-up 705 deaths occurred, 58.4% specifically due to breast cancer. Five- and 10-year breast cancer specific survival rates were 83.3% and 73.7%, respectively (stage I, 97.1% and 94.0%; stage II, 88.0% and 79.4%; stage III, 70.1% and 46.3%, and stage IV, 24.5% and 6.1%, respectively). The 5-year disease-specific survival rate increased from 73.5% in 1992-1995 to 86.4% in 2001-2005 (log rank, p<0.001). Multivariate analyses showed that prognosis was less favourable for women diagnosed between 1992 and 1995, for those whose route to diagnosis was not the screening programme, women aged ≥ 70 years, with stage IV tumours, with high grade lesions, and for women who received only palliative or symptomatic treatment. Adjusting for prognostic factors, surgeon's experience did not significantly appeared to affect survival of operated women.
In this centre survival from breast cancer improved markedly from 1992 to 2005. Breast cancer prognosis was influenced by both clinical and organisational variables. The quantification of the role of such factors affords valuable knowledge to improve cancer care in settings similar to the study hospital.
Available from: uiowa.edu
- "The main purpose of our study is to investigate the disparity in patients' utilization of high volume hospitals for breast cancer surgeries, focusing on how geographic distance affects patients' choice of high vs. low volume hospitals. Several retrospective cohort studies(Roohan et al. 1998, Bailie et al. 2007, Ingram et al. 2005, McKee et al. 2002, Nattinger et al. 2007, Chen et al. 2007, Gilligan et al. 2007) examined the relationship between hospital volume and long-term mortality for breast cancer surgeries. A significant higher hospital volume-better outcome relationship was reported in these studies. "
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ABSTRACT: Volume has been suggested as a surrogate quality indicator for breast cancer surgeries by several researchers. It is crucial to understand the underlying reasons as to why there is a disparity in utilization of high volume hospitals. However, the studies that investigated the mechanism underlying the disparity in high volume hospital utilization are very limited. The objectives of this study include: 1) examine the relationship between geographic differential distance and utilization of high volume hospitals; 2) investigate other demographic, socioeconomic and clinical factors that may affect patients' utilization of high volume hospitals. Multivariate logistic regressions were used to evaluate factors that impact patients' utilization of high volume hospitals. The study results showed that geographic distance is a significant factor that impedes patients' utilization of high volume hospitals, independent of patients' clinical, demographic, and socioeconomic characteristics. It was also found that white, non-Hispanic women, patients with higher education level are more likely to be admitted in high volume hospitals compared to low volume hospitals. These factors are also significant to patients' choice of medium vs. low volume hospitals. Geographic proximity is an important factor that affects patients' choice of hospital, and directing more patients to high volume hospitals should anticipate negative effects, such as increasing the cost of seeking care at high volume hospitals. Alternative strategies need to be developed to improve surgical outcomes without increasing patients' traveling related cost, such as enhancing the network between high volume hospitals and low volume hospitals, establishing radiation centers in rural areas.
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