Skip to main navigation menu Skip to main content Skip to site footer
##common.pageHeaderLogo.altText##

Original article

Vol. 149 No. 0304 (2019)

Impact of experience in breast cancer surgery on survival: the role of quality of care in a registry-based cohort

  • François Taban
  • Nadia Elia
  • Elisabetta Rapiti
  • Christoph Rageth
  • Gerald Fioretta
  • Simone Benhamou
  • Giang Than Lam
  • Emmanuel David-Montefiore
  • Christine Bouchardy
DOI
https://doi.org/10.4414/smw.2019.14704
Cite this as:
Swiss Med Wkly. 2019;149:w14704
Published
27.01.2019

Summary

AIMS OF THE STUDY

Previous studies have suggested that the surgeon’s experience in breast cancer surgery may affect patient survival. In this registry-based retrospective cohort study, we examined whether quality of care could partly explain this association.

METHODS

All invasive breast cancers operated on in the private sector between 2000 and 2009 were identified in the Geneva Cancer Registry and followed up for 5 years. Surgeons were classified according to their experience into three categories: ≤5, 6–10, >10 breast cancer operations performed per year. We extracted patient and tumour characteristics. Quality of care was scored as the proportion of 11 quality indicators correctly fulfilled for each patient. Breast cancer-specific mortality was examined with a Cox model adjusted for variables known to affect survival, surgeon experience, and quality of care.

RESULTS

A total of 1489 patients were operated on by 88 surgeons; 50 patients (3.4%) died from breast cancer during the 5 years of follow-up. Socioeconomic status and country of birth of the patients, as well as period of diagnosis, differed according to the surgeons’ experience. Quality of care provided improved with surgeon’s experience. Surgeons performing >10 operations/year more frequently assessed histology before surgery, excised sentinel lymph nodes, removed ≥10 lymph nodes, and prescribed adjuvant radiotherapy when indicated. Crude breast cancer-specific mortality was lower in patients treated by surgeons performing >10 compared with ≤5 operations/year (hazard ratio [HR] 0.34, 95% confidence interval [CI] 0.17–0.67; p = 0.002). The strength of the association decreased after adjustment for patient and tumour characteristics (HR 0.45, 95% CI 0.21–0.94; p = 0.034) and decreased further after adjustment for quality of care (HR 0.51, 95% CI 0.24–1.08, p = 0.078).

CONCLUSIONS

The association between surgeon’s experience and 5-year breast cancer survival is at least partly explained by quality of care, patient and tumour characteristics. Further investigations on the impact of other quality indicators such as multidisciplinary networks are needed.

References

  1. Sainsbury R, Haward R, Round C, Rider L, Johnston C. Influence of clinician workload and patterns of treatment on survival from breast cancer. Lancet. 1995;345(8960):1265–70. doi:.https://doi.org/10.1016/S0140-6736(95)90924-9
  2. Gillis CR, Hole DJ. Survival outcome of care by specialist surgeons in breast cancer: a study of 3786 patients in the west of Scotland. BMJ. 1996;312(7024):145–8. doi:.https://doi.org/10.1136/bmj.312.7024.145
  3. Stefoski Mikeljevic J, Haward RA, Johnston C, Sainsbury R, Forman D. Surgeon workload and survival from breast cancer. Br J Cancer. 2003;89(3):487–91. doi:.https://doi.org/10.1038/sj.bjc.6601148
  4. Skinner KA, Helsper JT, Deapen D, Ye W, Sposto R. Breast cancer: do specialists make a difference? Ann Surg Oncol. 2003;10(6):606–15. doi:.https://doi.org/10.1245/ASO.2003.06.017
  5. Allgood PC, Bachmann MO. Effects of specialisation on treatment and outcomes in screen-detected breast cancers in Wales: cohort study. Br J Cancer. 2006;94(1):36–42. doi:.https://doi.org/10.1038/sj.bjc.6602894
  6. Bailie K, Dobie I, Kirk S, Donnelly M. Survival after breast cancer treatment: the impact of provider volume. J Eval Clin Pract. 2007;13(5):749–57. doi:.https://doi.org/10.1111/j.1365-2753.2006.00748.x
  7. Clayforth C, Fritschi L, McEvoy SP, Byrne MJ, Ingram D, Sterrett G, et al. Five-year survival from breast cancer in Western Australia over a decade. Breast. 2007;16(4):375–81. doi:.https://doi.org/10.1016/j.breast.2007.01.010
  8. Nattinger AB, Laud PW, Sparapani RA, Zhang X, Neuner JM, Gilligan MA. Exploring the surgeon volume outcome relationship among women with breast cancer. Arch Intern Med. 2007;167(18):1958–63. doi:.https://doi.org/10.1001/archinte.167.18.1958
  9. Chen CS, Liu TC, Lin HC, Lien YC. Does high surgeon and hospital surgical volume raise the five-year survival rate for breast cancer? A population-based study. Breast Cancer Res Treat. 2008;110(2):349–56. doi:.https://doi.org/10.1007/s10549-007-9715-4
  10. Guller U, Safford S, Pietrobon R, Heberer M, Oertli D, Jain NB. High hospital volume is associated with better outcomes for breast cancer surgery: analysis of 233,247 patients. World J Surg. 2005;29(8):994–9, discussion 999–1000. doi:.https://doi.org/10.1007/s00268-005-7831-z
  11. Hébert-Croteau N, Brisson J, Lemaire J, Latreille J, Pineault R. Investigating the correlation between hospital of primary treatment and the survival of women with breast cancer. Cancer. 2005;104(7):1343–8. doi:.https://doi.org/10.1002/cncr.21336
  12. Simunovic M, Rempel E, Thériault ME, Coates A, Whelan T, Holowaty E, et al. Influence of hospital characteristics on operative death and survival of patients after major cancer surgery in Ontario. Can J Surg. 2006;49(4):251–8.
  13. Gilligan MA, Neuner J, Zhang X, Sparapani R, Laud PW, Nattinger AB. Relationship between number of breast cancer operations performed and 5-year survival after treatment for early-stage breast cancer. Am J Public Health. 2007;97(3):539–44. doi:.https://doi.org/10.2105/AJPH.2005.075663
  14. Gutierrez JC, Hurley JD, Housri N, Perez EA, Byrne MM, Koniaris LG. Are many community hospitals undertreating breast cancer?: lessons from 24,834 patients. Ann Surg. 2008;248(2):154–62. doi:.https://doi.org/10.1097/SLA.0b013e31816c4030
  15. Peltoniemi P, Peltola M, Hakulinen T, Häkkinen U, Pylkkänen L, Holli K. The effect of hospital volume on the outcome of breast cancer surgery. Ann Surg Oncol. 2011;18(6):1684–90. doi:.https://doi.org/10.1245/s10434-010-1514-1
  16. Roohan PJ, Bickell NA, Baptiste MS, Therriault GD, Ferrara EP, Siu AL. Hospital volume differences and five-year survival from breast cancer. Am J Public Health. 1998;88(3):454–7. doi:.https://doi.org/10.2105/AJPH.88.3.454
  17. Jonker FHW, Hagemans JAW, Verhoef C, Burger JWA. The impact of hospital volume on perioperative outcomes of rectal cancer. Eur J Surg Oncol. 2017;43(10):1894–900. doi:.https://doi.org/10.1016/j.ejso.2017.07.009
  18. Manchon-Walsh P, Aliste L, Espinàs JA, Prades J, Guarga A, Balart J, et al.; Catalonian Rectal Cancer Group. Improving survival and local control in rectal cancer in Catalonia (Spain) in the context of centralisation: A full cycle audit assessment. Eur J Surg Oncol. 2016;42(12):1873–80. doi:.https://doi.org/10.1016/j.ejso.2016.08.009
  19. Gooiker GA, van Gijn W, Post PN, van de Velde CJ, Tollenaar RA, Wouters MW. A systematic review and meta-analysis of the volume-outcome relationship in the surgical treatment of breast cancer. Are breast cancer patients better of with a high volume provider? Eur J Surg Oncol. 2010;36(Suppl 1):S27–35. doi:.https://doi.org/10.1016/j.ejso.2010.06.024
  20. Hébert-Croteau N, Brisson J, Pineault R. Review of organizational factors related to care offered to women with breast cancer. Epidemiol Rev. 2000;22(2):228–38. doi:.https://doi.org/10.1093/oxfordjournals.epirev.a018035
  21. Hogan AM, Winter DC. Does practice make perfect? Ann Surg Oncol. 2008;15(5):1267–70. doi:.https://doi.org/10.1245/s10434-007-9804-y
  22. OECD Data. Health spending: https://data.oecd.org/healthres/health-spending.htm (accessed on the 28 September 2018)
  23. Reinhardt UE. The Swiss health system: regulated competition without managed care. JAMA. 2004;292(10):1227–31. doi:.https://doi.org/10.1001/jama.292.10.1227
  24. Ess S, Savidan A, Frick H, Rageth Ch, Vlastos G, Lütolf U, et al. Geographic variation in breast cancer care in Switzerland. Cancer Epidemiol. 2010;34(2):116–21. doi:.https://doi.org/10.1016/j.canep.2010.01.008
  25. Fisch T, Pury P, Probst N, Bordoni A, Bouchardy C, Frick H, et al. Variation in survival after diagnosis of breast cancer in Switzerland. Ann Oncol. 2005;16(12):1882–8. doi:.https://doi.org/10.1093/annonc/mdi404
  26. Report WC. Lyon: International Agency for Research on Cancer (IARC); 2008.
  27. Sant M, Chirlaque Lopez MD, Agresti R, Sánchez Pérez MJ, Holleczek B, Bielska-Lasota M, et al.; EUROCARE-5 Working Group. Survival of women with cancers of breast and genital organs in Europe 1999-2007: Results of the EUROCARE-5 study. Eur J Cancer. 2015;51(15):2191–205. doi:.https://doi.org/10.1016/j.ejca.2015.07.022
  28. Benchimol EI, Smeeth L, Guttmann A, Harron K, Moher D, Petersen I, et al.; RECORD Working Committee. The REporting of studies Conducted using Observational Routinely-collected health Data (RECORD) statement. PLoS Med. 2015;12(10):e1001885. doi:.https://doi.org/10.1371/journal.pmed.1001885
  29. von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP ; STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet. 2007;370(9596):1453–7. doi:.https://doi.org/10.1016/S0140-6736(07)61602-X
  30. Autorisation de la commission d'experts du secret professionnel en matière de recherche médicale: https://www.unige.ch/medecine/rgt/files/7914/6462/0509/Article321bis_1994_Texte_Commission_Experts.pdf (accessed on the 28 September 2018)
  31. World Health Organization. ICD-O International classification of diseases for oncology. 3rd ed. Geneva: WHO; 2000. 240 p.
  32. TNM Classification of Malignant Tumours (UICC). 6 ed. New York: John Wiley & Sons, Inc.; UICC; 2002 2002.
  33. Rosselli Del Turco M, Ponti A, Bick U, Biganzoli L, Cserni G, Cutuli B, et al. Quality indicators in breast cancer care. Eur J Cancer. 2010;46(13):2344–56. doi:.https://doi.org/10.1016/j.ejca.2010.06.119
  34. Goldhirsch A, Wood WC, Gelber RD, Coates AS, Thürlimann B, Senn HJ. Meeting highlights: updated international expert consensus on the primary therapy of early breast cancer. J Clin Oncol. 2003;21(17):3357–65. doi:.https://doi.org/10.1200/JCO.2003.04.576
  35. Taban F, Rapiti E, Fioretta G, Wespi Y, Weintraub D, Hugli A, et al. Breast cancer management and outcome according to surgeon’s affiliation: a population-based comparison adjusted for patient’s selection bias. Ann Oncol. 2013;24(1):116–25. doi:.https://doi.org/10.1093/annonc/mds285
  36. Hébert-Croteau N, Roberge D, Brisson J. Provider’s volume and quality of breast cancer detection and treatment. Breast Cancer Res Treat. 2007;105(2):117–32. doi:.https://doi.org/10.1007/s10549-006-9439-x
  37. Tamirisa NP, Sheffield KM, Parmar AD, Zimmermann CJ, Adhikari D, Vargas GM, et al. Surgeon and Facility Variation in the Use of Minimally Invasive Breast Biopsy in Texas. Ann Surg. 2015;262(1):171–8. doi:.https://doi.org/10.1097/SLA.0000000000000883
  38. Eberth JM, Xu Y, Smith GL, Shen Y, Jiang J, Buchholz TA, et al. Surgeon influence on use of needle biopsy in patients with breast cancer: a national medicare study. J Clin Oncol. 2014;32(21):2206–16. doi:.https://doi.org/10.1200/JCO.2013.52.8257
  39. Posther KE, McCall LM, Blumencranz PW, Burak WE, Jr, Beitsch PD, Hansen NM, et al. Sentinel node skills verification and surgeon performance: data from a multicenter clinical trial for early-stage breast cancer. Ann Surg. 2005;242(4):593–9, discussion 599–602.
  40. McDermott AM, Wall DM, Waters PS, Cheung S, Sibbering M, Horgan K, et al.; ABS Audit Committee. Surgeon and breast unit volume-outcome relationships in breast cancer surgery and treatment. Ann Surg. 2013;258(5):808–13, discussion 813–4. doi:.https://doi.org/10.1097/SLA.0b013e3182a66eb0
  41. Yen TW, Laud PW, Sparapani RA, Nattinger AB. Surgeon specialization and use of sentinel lymph node biopsy for breast cancer. JAMA Surg. 2014;149(2):185–92. doi:.https://doi.org/10.1001/jamasurg.2013.4350
  42. Yen TW, Li J, Sparapani RA, Laud PW, Nattinger AB. The interplay between hospital and surgeon factors and the use of sentinel lymph node biopsy for breast cancer. Medicine (Baltimore). 2016;95(31):e4392. doi:.https://doi.org/10.1097/MD.0000000000004392
  43. Kong AL, Pezzin LE, Nattinger AB. Identifying patterns of breast cancer care provided at high-volume hospitals: a classification and regression tree analysis. Breast Cancer Res Treat. 2015;153(3):689–98. doi:.https://doi.org/10.1007/s10549-015-3561-6
  44. Kingsmore D, Hole D, Gillis C. Why does specialist treatment of breast cancer improve survival? The role of surgical management. Br J Cancer. 2004;90(10):1920–5. doi:.https://doi.org/10.1038/sj.bjc.6601846
  45. Ma M, Bell J, Campbell S, Basnett I, Pollock A, Taylor I. Breast cancer management: is volume related to quality? Clinical Advisory Panel. Br J Cancer. 1997;75(11):1652–9. doi:.https://doi.org/10.1038/bjc.1997.281
  46. Ingram DM, McEvoy SP, Byrne MJ, Fritschi L, Joseph DJ, Jamrozik K. Surgical caseload and outcomes for women with invasive breast cancer treated in Western Australia. Breast. 2005;14(1):11–7. doi:.https://doi.org/10.1016/j.breast.2004.06.008
  47. Morche J, Mathes T, Pieper D. Relationship between surgeon volume and outcomes: a systematic review of systematic reviews. Syst Rev. 2016;5(1):204. doi:.https://doi.org/10.1186/s13643-016-0376-4
  48. Kesson EM, Allardice GM, George WD, Burns HJ, Morrison DS. Effects of multidisciplinary team working on breast cancer survival: retrospective, comparative, interventional cohort study of 13 722 women. BMJ. 2012;344(apr26 1):e2718. doi:.https://doi.org/10.1136/bmj.e2718

Most read articles by the same author(s)