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Lesar M, Stanec M, Banović M. Significance of the Relative Size of a Breast Tumor in Deciding the Method of Surgical Treatment. TUMORI JOURNAL 2018. [DOI: 10.1177/030089160609200104] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Miroslav Lesar
- Department of Surgical Oncology, University Hospital for Tumors, Zagreb, Croatia
| | - Mladen Stanec
- Department of Surgical Oncology, University Hospital for Tumors, Zagreb, Croatia
| | - Miroslav Banović
- Department of Surgical Oncology, University Hospital for Tumors, Zagreb, Croatia
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Brundage M, Danielson B, Pearcey R, Bass B, Pickles T, Bahary JP, Peng Y, Wallace D, Mackillop W. A criterion-based audit of the technical quality of external beam radiotherapy for prostate cancer. Radiother Oncol 2013; 107:339-45. [PMID: 23830469 DOI: 10.1016/j.radonc.2013.04.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2012] [Revised: 04/25/2013] [Accepted: 04/26/2013] [Indexed: 02/07/2023]
Abstract
PURPOSE To evaluate the technical quality of external beam radiotherapy for prostate cancer in Canada. METHODS This was a multi-institution, retrospective study of a random sample of patients undergoing radiotherapy (RT) for prostate cancer in Canada. Patterns of care were determined by abstracting details of the patients' management from original records. The quality of patient's technical care was measured against a previously published, comprehensive suite of quality indicators. RESULTS 32 of the 37 RT centres participated. The total study population of 810 patients included 25% low-risk, 44% intermediate-risk, and 28% high-risk cases. 649 received external beam RT (EBRT) only, for whom compliance with 12 indicators of the quality of pre-treatment assessment ranged from 56% (sexual function documented) to 96% (staging bone scan obtained in high-risk patients). Compliance with treatment-related indicators ranged from 78% (dose to prostate ≥74 Gy in intermediate risk patients not receiving hormone therapy) to 100% (3DCRT or IMRT plan). Compliance varied among centres; no centre demonstrated 100% compliance on all indicators and every centre was 100% compliant on at least some indicators. The number of assessment-related indicators (n=13) with which a given centre was 100% compliant ranged from 4 to 11 (median 7) and the number of the treatment-specific indicators (n=8) with which a given centre was 100% compliant ranged from 6 to 8 (median 8). ADT therapy was utilised in most high-risk cases (191, 92.3%). CONCLUSIONS While patterns of prostate cancer care in Canada vary somewhat, compliance on the majority of quality indicators is very high. However, all centres showed room for improvement on several indicators and few individual patients received care that met target benchmarks on all quality measures. This variation is particularly important for indicators such as delivered dose where impact on disease outcome is known to exist, and suggests that quality improvement programmes have the potential to further improve quality of care.
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Affiliation(s)
- Michael Brundage
- Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, Ontario, Canada.
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Brennan M, Spillane A. Uptake and predictors of post-mastectomy reconstruction in women with breast malignancy – Systematic review. Eur J Surg Oncol 2013; 39:527-41. [DOI: 10.1016/j.ejso.2013.02.021] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2012] [Revised: 02/13/2013] [Accepted: 02/20/2013] [Indexed: 01/20/2023] Open
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Peltoniemi P, Huhtala H, Holli K, Pylkkänen L. Effect of surgeon's caseload on the quality of surgery and breast cancer recurrence. Breast 2012; 21:539-43. [DOI: 10.1016/j.breast.2012.04.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2012] [Accepted: 04/18/2012] [Indexed: 11/30/2022] Open
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Han D, Hogeveen S, Sweet Goldstein M, George R, Brezden-Masley C, Hoch J, Haq R, Simmons CE. Is knowledge translation adequate? A quality assurance study of staging investigations in early stage breast cancer patients. Breast Cancer Res Treat 2011; 132:1-7. [PMID: 21947708 DOI: 10.1007/s10549-011-1786-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2011] [Accepted: 09/15/2011] [Indexed: 12/01/2022]
Abstract
After primary surgery, patients diagnosed with early stage breast cancer undergo radiological investigations based on pathologic stage of disease to rule out distant metastases. Published guidelines can aid clinicians in determining which tests are appropriate based on stage of disease. We wished to assess the consistency of radiological staging in an academic community oncology setting with standard guidelines and to determine the overall impact of non-adherence to these guidelines. A retrospective cohort study was conducted for new breast cancer patients seen at a single institution between January 2009 and April 2010. Patients were included if initial diagnosis and primary surgery was at this institution. Pathologic stage and radiological tests completed were recorded. A literature review was performed and the results were compared with those from this study to determine overall adherence rates. Subsequently, a cost analysis was performed to determine the financial impact at this centre. 231 patients met eligibility criteria for inclusion in this study. A large proportion of patients were over-staged with 129 patients (55%) undergoing unnecessary investigations according to guidelines. Specifically, 59% of stage I patients and 58% of stage II patients were over-investigated. Distant metastases at the time of diagnosis were found in three patients, all of whom had stage III disease (1.3%). The literature reviewed revealed similar non-adherence rates in other centres. The estimated cost of such non-adherence is in the range of $78 (CDN) per new early stage breast cancer patient seen at this centre. This oncology centre has a low adherence to practice guidelines for staging investigations in breast cancer patients, with 55% of patients undergoing unnecessary tests. Very few patients had metastases at diagnosis, and all had pathological stage III disease. Efforts may need to focus on improving knowledge translation across clinical oncology settings to increase guideline adherence.
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Affiliation(s)
- Dolly Han
- Department of Hematology and Oncology, St. Michael's Hospital, Toronto, ON M5B 1W8, Canada.
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Dickson-Witmer D, Bleznak AD, Kennedy JS, Stewart AK, Palis BE, Bailey L, Laidley AL, Penman EJ. Breast Cancer Care in the Community: Challenges, Opportunities, and Outcomes. Surg Oncol Clin N Am 2011; 20:555-80, ix. [DOI: 10.1016/j.soc.2011.01.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Breast cancer care compared with clinical Guidelines: an observational study in France. BMC Public Health 2011; 11:45. [PMID: 21251274 PMCID: PMC3037311 DOI: 10.1186/1471-2458-11-45] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2010] [Accepted: 01/20/2011] [Indexed: 11/18/2022] Open
Abstract
Background Great variability in breast cancer (BC) treatment practices according to patient, tumour or organisation of care characteristics has been reported but the relation between these factors is not well known. In two French regions, we measured compliance with Clinical Practice Guidelines for non-metastatic BC care management and identified factors associated with non-compliance at clinical and organisational levels. Methods Eligible patients had invasive unilateral BC without distant metastases and at least two contacts with one of the two regional healthcare systems (2003-2004) in the first year after diagnosis. Medical data were collected from patient medical records in all public and private hospitals (99 hospitals). The care process was defined by 20 criteria: clinical decisions for treatment and therapeutic procedures. Each criterion was classified according to level of compliance ("Compliant", "Justifiable" and "Not Compliant") and factors of non-compliance were identified (mixed effect logistic regression). Results 926 women were included. Non-compliance with clinical decisions for treatment was associated with older patient age (OR 2.1; 95%CI: 1.3-3.6) and region (OR 3.0; 95%CI: 1.2-7.4). Non-compliance with clinical decisions for radiotherapy was associated with lymph node involvement or the presence of peritumoural vascular invasion (OR 1.5; 95%CI: 1.01-2.3) and non-compliance with overall treatment (clinical decisions for treatment + therapeutic procedures) was associated with the presence of positive lymph nodes (OR 2.0; 95%CI: 1.2-3.3), grade III versus grade I (OR 2.9; 95%CI: 1.4-6.2), and one region of care versus another (OR 3.5; 95%CI: 1.7-7.1). Finally, heterogeneity of compliance in overall treatment sequence was identified between local cancer units (p < 0.05). Conclusion This study provides interesting insights into factors of non-compliance in non-metastatic BC management and could lead to quality care improvements.
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Abstract
The role of the breast cancer surgeon has changed from one with performance of one operation, to a position in which the surgeon is the patient's initial contact, leader of a multidisciplinary team, the clinical leader who ensures that the patient receives the most appropriate breast cancer treatment and then also receives follow up and surveillance services. Breast conservation rates, patient satisfaction rates, clear margins, use of oncoplastic surgical techniques, appropriate referral to other consultants, clinical trial referral, and survival rates are all higher when patients are cared for by breast-focused surgeons. This new role requires greater time both before and after surgery to provide the proper planning and care for these patients. Women with breast cancer should have access to these dedicated breast-focused surgeons. Recognition of this expanding responsibility and reimbursement for this time and expertise is needed so that women with breast cancer can be offered the highest quality of care.
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Chowdhury MM, Dagash H, Pierro A. A systematic review of the impact of volume of surgery and specialization on patient outcome. Br J Surg 2007; 94:145-61. [PMID: 17256810 DOI: 10.1002/bjs.5714] [Citation(s) in RCA: 422] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND METHODS Volume of surgery and specialization may affect patient outcome. Articles examining the effects of one or more of three variables (hospital volume of surgery, surgeon volume and specialization) on outcome (measured by length of hospital stay, mortality and complication rate) were analysed. Reviews, opinion articles and observational studies were excluded. The methodological quality of each study was assessed, a correlation between the variables analysed and the outcome accepted if it was significant. RESULTS The search identified 55,391 articles published between 1957 and 2002; 1075 were relevant to the study, of which 163 (9,904,850 patients) fulfilled the entry criteria. These 163 examined 42 different surgical procedures, spanning 13 surgical specialities. None were randomized and 40 investigated more than one variable. Hospital volume was reported in 127 studies; high-volume hospitals had significantly better outcomes in 74.2 per cent of studies, but this effect was limited in prospective studies (40 per cent). Surgeon volume was reported in 58 studies; high-volume surgeons had significantly better outcomes in 74 per cent of studies. Specialization was reported in 22 studies; specialist surgeons had significantly better outcomes than general surgeons in 91 per cent of studies. The benefit of high surgeon volume and specialization varied in magnitude between specialities. CONCLUSION High surgeon volume and specialization are associated with improved patient outcome, while high hospital volume is of limited benefit.
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Affiliation(s)
- M M Chowdhury
- Department of Paediatric Surgery, Institute of Child Health and Great Ormond Street Hospital for Children, London WC1N 1EH, UK.
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Hébert-Croteau N, Roberge D, Brisson J. Provider’s volume and quality of breast cancer detection and treatment. Breast Cancer Res Treat 2006; 105:117-32. [PMID: 17186361 DOI: 10.1007/s10549-006-9439-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2006] [Accepted: 10/24/2006] [Indexed: 11/26/2022]
Abstract
For many health conditions, the process or result of medical procedures improves with increasing caseload. The evidence about breast cancer has not been thoroughly assessed. This review synthesizes the literature about provider's volume and performance in either breast cancer screening with mammography or treatment. Articles published in English between 1990 and 2006 were identified by a computerized search and by review of reference lists. In screening with mammography, the reading volume of the radiologist and the screening volume of the facility influence different components of performance. The most conclusive evidence for breast cancer treatment concerns the association between the surgeon's caseload and the process or end-results of therapeutic interventions. Although the mechanisms of these associations still need to be clarified, large provider's volume in screening mammography or breast cancer treatment is often related to the quality of medical interventions.
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Affiliation(s)
- Nicole Hébert-Croteau
- Direction des Systèmes de Soins et Services, Institut National de Santé Publique du Québec, 190 Boul. Crémazie Est, Bureau 2.24, Montréal, Quebec, Canada.
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Ottevanger PB, De Mulder PHM. The quality of chemotherapy and its quality assurance. Eur J Surg Oncol 2005; 31:656-66. [PMID: 15893906 DOI: 10.1016/j.ejso.2005.02.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2004] [Revised: 11/11/2004] [Accepted: 02/10/2005] [Indexed: 11/27/2022] Open
Abstract
AIMS Assessment of the quality of chemotherapy care and its quality assurance in clinical trials and daily practice. METHODS Using Medline, literature was searched combining the following words: quality assurance or quality of care, combined with anti-neoplastic agents. The bibliography of each article was reviewed for additional literature. Those reports in English, French, German or Dutch focusing quality assurance or quality of care and chemotherapy were selected. RESULTS One hundred and five articles were selected by Medline and after review and adding of additional literature 53 articles remained. In clinical trials information on quality of chemotherapy is sparse. Different cooperative groups reported on suboptimal dosing, suboptimal registration of chemotherapy and several trials indicated that suboptimal dosing led to impaired outcome. Most quality assurance activities in clinical trials are concerned with audit and feedback and on-site visits. In daily practice the quality of chemotherapy is mostly impaired by the fact that it is not given although indicated and if it is given non-evidence based chemotherapy or administration schedules and reduced dose intensity decrease the quality of care. Especially, age, comorbidity and socio-economic status reduce the chance of receiving good quality of care regarding chemotherapy. Activities mostly used for quality assurance are generation of guidelines, specialisation and multidisciplinary care. CONCLUSIONS Most quality assurance activities in clinical trials and daily practice are directed to structure and process parameters. More evidence that quality of care is related to outcome should be sought. Quality assurance in daily practice should aim at guideline implementation, specialisation and multidisciplinary care and should pay attention especially to the older patients, patients with comorbidity and patients from lower socio-economic classes.
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Affiliation(s)
- P B Ottevanger
- Division Medical Oncology, Radboud University Nijmegen Medical Centre, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands.
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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; 14:11-7. [PMID: 15695075 DOI: 10.1016/j.breast.2004.06.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2004] [Revised: 05/16/2004] [Accepted: 06/03/2004] [Indexed: 11/30/2022] Open
Abstract
We have assessed the outcomes for all women diagnosed with invasive breast cancer in Western Australia during 1989, 1994 and 1999, and compared the results for surgeons who treat 20 or more cases per year with those of surgeons who treat less. Women treated by high caseload surgeons were more likely to retain their breast (53.3% vs. 36.7%, p<0.001), have adjuvant radiotherapy (50.0% vs. 30.6%, p<0.001), and be alive after 4 years (1989, 86% vs. 82%; 1994, 89% vs. 84%; 1999, 90% vs. 79%, HR 0.71, p=0.03). Adjusting for age and year of diagnosis, women were not more likely to be treated with adjuvant chemotherapy (29.2% vs. 20.9%, p=0.28). In 1989 35% of women were treated by high caseload surgeons. By 1999 this had risen to 82%. The results confirm that women treated by high caseload surgeons have better outcomes.
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Affiliation(s)
- D M Ingram
- Breast Centre, Sir Charles Gairdner Hospital, Western Australia, Australia
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Daly JM. Society of Surgical Oncology Presidential Address: Volume, Outcome, and Surgical Specialization. Ann Surg Oncol 2004; 11:107-14. [PMID: 14761908 DOI: 10.1245/aso.2004.08.921] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- John M Daly
- Temple University School of Medicine, 3420 North Broad Street, Room 101, Philadelphia, PA 19140, USA.
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Abstract
BACKGROUND Subspecialization in general surgery is being encouraged by various surgical societies. The aim of this study was to view attitudes of Royal Australasian College of Surgeons (RACS) trainees to subspecialization in surgery, in particular, breast -surgery. METHODS A postal questionnaire survey of registered RACS basic and advanced surgical trainees was conducted in February 2002. Trainees were asked to nominate their preferred specialty and to indicate the level of support and interest for subspecialty training in breast surgery. Trainees indicating breast surgery as their preferred career choice were then asked to nominate their reasons for choosing breast surgery, preferred options for cross-specialty training and for vocation specifications such as a continuing 'on-call' responsibility. RESULTS Trainees returned 291 of 1049 (28%) completed questionnaires. One hundred and sixty-nine trainees felt that the concept of breast subspecialization in general surgery was reasonable (58%). For all respondents, the most popular specialty choices were plastic surgery (15.8%), orthopaedics (15.5%) and general surgery (15.4%). Breast surgery was chosen by 14 of 291 (4.8%) respondents as their first specialty preference and a further 25 respondents as their second specialty preference. Of 189 trainees who did not choose breast surgery as their preferred specialty, 45% stated repetitive stress, escalating litigation or demanding patients as deterrent factors. Only 36% of trainees interested in breast surgery were interested in undertaking after hours 'on-call' work as a consultant, although 36 of 39 (92%) were interested in other forms of general or subspecialty elective surgical operating (i.e., endocrine surgery, surgical oncology) after completion of their training. According to trainees with an interest in breast surgery, the two most important aspects requiring inclusion in the proposed provisional training program were breast reconstruction (38%) and breast screen assessment (34%). CONCLUSION Breast surgery is an unpopular subspecialty for RACS trainees. Breast surgery is likely to experience increasing -problems with recruitment unless the skill base is reviewed and revised in line with the aspirations and needs of today's trainees.
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Affiliation(s)
- James Kollias
- Breast Unit and Women's Health Centre, Royal Adelaide Hospital Cancer Centre, Adelaide University Department of Surgery, Adelaide, South Australia, Australia.
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Pagano E, Ponti A, Gelormino E, Merletti F, Mano MP. An economic evaluation of the optimal workload in treating surgical patients in a breast unit. Eur J Cancer 2003; 39:748-54. [PMID: 12651199 DOI: 10.1016/s0959-8049(02)00808-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
A breast unit is a cancer centre specialised in the diagnosis and treatment of patients with breast cancer. The high level of specialised skills involved in running a breast unit makes it an expensive pattern of care. The European Society of Mastology (EUSOMA) recommends a minimum caseload of 150 cases sufficient to maintain expertise for each team member and to ensure cost-effective working of the breast unit. Specific economic analysis evaluating main diagnostic services (radiology and pathology) and treatment are needed. The present study assesses the activity level at which the breast unit represents good value for money in surgically-treated patients. Cost assessment is realised by defining a cost function according to the following assumptions: cost function input is personnel costs and technical equipment and output is the number of newly diagnosed cases of primary breast cancer admitted to the breast care unit each year. The increase from 50 new cancer cases per year to 100 will reduce average costs by almost 50%. Cost reduction is important up to a volume of 200 new cases per year. For economic investment to be justified, it is desirable that intake rises to at least 200 new cases per year. Our result is in-line with the EUSOMA recommendation.
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Affiliation(s)
- E Pagano
- Unit of Cancer Epidemiology, University of Turin and CPO-Piemonte, Italy.
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Beam CA, Conant EF, Sickles EA. Association of volume and volume-independent factors with accuracy in screening mammogram interpretation. J Natl Cancer Inst 2003; 95:282-90. [PMID: 12591984 DOI: 10.1093/jnci/95.4.282] [Citation(s) in RCA: 133] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Early detection of breast cancer is associated with the accurate reading of screening mammograms, but factors that influence reading accuracy are not well understood. We thus investigated whether reading volume and other factors were independently associated with accuracy in reading screening mammograms in a population of U.S. radiologists. METHODS A random selection of 110 of 292 radiologists who agreed to participate, if selected, interpreted screening mammograms from 148 randomly selected women. Original index mammograms (i.e., mediolateral oblique and craniocaudal views of each breast) were used; comparison original mammograms were provided when available. Radiologist-level and facility-level factors were surveyed. Two standard metrics of screening accuracy, both based on receiver operating characteristic curves, were analyzed. The influence of volume on accuracy after controlling for other factors was assessed with multiple regression analysis. RESULTS Current reading volume was not statistically significantly associated with interpretive accuracy. More recently trained radiologists interpreted mammograms more accurately than those trained earlier (-0.76% [95% confidence interval (CI) = -1.75% to -0.02%] reduction in sensitivity per year since residency). Facility-level factors that were statistically significantly and independently associated with better accuracy were the number of diagnostic breast imaging examinations and image-guided breast interventional procedures performed (0.55% [95% CI = 0.11% to 2.40%] increase in accuracy per examination or procedure offered), being classified as a comprehensive breast diagnostic and/or screening center or freestanding mammography center (1.39% [95% CI = 0.15% to 3.82%] higher than a hospital radiology department or multispecialty medical clinic), and being a facility that practiced double reading (1.61% [95% CI = 1.99% to 11.65%]) higher than in a facility without such practice). CONCLUSIONS Individual radiologists' current reading volume was not statistically significantly associated with accuracy in reading screening mammograms, but several other factors were. Expertise reflects a complex multifactorial process that needs further clarification.
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Affiliation(s)
- Craig A Beam
- Department of Radiology, Medical College of Wisconsin, Milwaukee, WI, USA.
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Wilkinson NW, Shahryarinejad A, Winston JS, Watroba N, Edge SB. Concordance with breast cancer pathology reporting practice guidelines. J Am Coll Surg 2003; 196:38-43. [PMID: 12517547 DOI: 10.1016/s1072-7515(02)01627-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Accurate pathology reporting is important for treatment of breast cancer. The College of American Pathologists (CAP) distributed guidelines for reporting cancer specimens in 1998. The aim of this study was to determine community-wide concordance with CAP breast cancer reporting guidelines. STUDY DESIGN Pathology reporting of stage I and II breast cancers was examined for adherence to CAP guidelines. Pathology reports were reviewed from 100 consecutive cases of invasive breast cancers referred to Roswell Park Cancer Institute in 1998 to 1999 from community hospitals after excisional breast biopsy and 20 consecutive cases with excisional biopsy at RPCI. Adherence to CAP guidelines for clinically relevant items was determined from the original pathology report in each case. RESULTS One hundred one cases met the inclusion criteria. Most reports did not include at least one of the guideline required elements. Surgical margins were inked in only 77%, and the margins oriented in only 25% of patients. Many specimens were not oriented by the surgeon. Grade was reported in most cases, but the Bloom Scarf Richardson grade was reported in only 6%. The presence or absence of lymphovascular invasion, and of coexisting in situ disease, was reported in 57% and 71%, respectively. The extent and type of in situ disease was reported in 47% and 49%, respectively. CONCLUSIONS Breast cancer pathology reporting varies widely. Key elements that affect treatment are often omitted. These include gross description and size, orientation and involvement of surgical margins, and description of histologic features, including Bloom Scarf Richardson reporting of grade and the extent of an in situ component. Passive distribution of CAP practice guidelines might be insufficient to accomplish community-wide quality improvement in breast pathology reporting.
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Affiliation(s)
- Neal W Wilkinson
- Department of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, NY 14263, USA
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Wanzel KR, Brown MH, Anastakis DJ, Regehr G. Reconstructive Breast Surgery: Referring Physician Knowledge and Learning Needs. Plast Reconstr Surg 2002. [DOI: 10.1097/00006534-200211000-00008] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
PURPOSE To critically review studies that describe patterns of care for breast cancer patients and to examine the data sources used for case identification and determining patterns of care. METHODS We searched the MEDLINE database (National Library of Medicine, Bethesda, MD) in August 2001 for studies of breast cancer care published from January 1985 to June 2001. Thirty-eight articles, describing 32 studies, met the inclusion criteria for this review. RESULTS According to the patterns of care literature, approximately 10% of women do not have an axillary lymph node dissection, 11% to 26% do not have their hormone receptor status reported, 20% do not receive radiation after breast-conserving surgery, and 30% to 70% of women with lymph node-positive breast cancer are not prescribed tamoxifen. Twenty-five (78%) of the studies relied on cancer registries for case identification. Cancer registries (47%) and the medical record (38%) were the most frequent sources of data on process of care. Twenty percent of the articles reported using more than one data source to determine patterns of care. CONCLUSION Although more patterns of care research has taken place in breast cancer than in any other oncologic condition, we found the available data had many limitations. These limitations highlight the challenges of quality-of-care research. To track changes in the quality of cancer care that may result from our rapidly transforming health care system, we need reliable data on the quality of current practice.
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Affiliation(s)
- Jennifer L Malin
- Department of Medicine, Jonsson Comprehensive Cancer Center, University of California Los Angeles, 90095-1736, USA.
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Pearson ML, Ganz PA, McGuigan K, Malin JR, Adams J, Kahn KL. The case identification challenge in measuring quality of cancer care. J Clin Oncol 2002; 20:4353-60. [PMID: 12409335 DOI: 10.1200/jco.2002.05.527] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The delivery of quality care to all patients with cancer has been named as a national priority within the American health care system. This article addresses the issues critical to case identification in cancer quality measurement and recommends possible strategies for accurately identifying a population of cancer patients. METHODS We present the measurement issues associated with the basic challenges of case identification strategies for quality measurement. We discuss two basic challenges: (1) accurately identifying all patients with the defining characteristics (eg, a diagnosis of breast cancer), and (2) identifying only patients with these characteristics. RESULTS Possible options for identifying newly diagnosed patients include using claims or other administrative data, cancer registries, cancer registry rapid case ascertainment, pathology laboratories, and physicians' offices. In the published literature, the sensitivity of claims varies from 75% to 95%, whereas central registries must have a 90% completeness rate to be certified. Most of these approaches, however, involve limitations to obtaining valid and comparable data across multiple settings. CONCLUSION Using an existing data collection system staffed by skilled data collectors and managers should result in substantially more accurate and timely data. Registry officials and the government agencies that provide their support should be encouraged to adopt quality-of-care analyses as an important purpose of the registry system and to enhance their capacity to rapidly ascertain cases, collect the appropriate identifying information needed for patient contact, and verify stage at diagnosis. In order to meet the growing demand for timely, accurate information about quality of care, registries are likely to require additional support so they can enhance their capacity to rapidly ascertain cases, collect the appropriate identifying information needed for patient contact, and verify stage at diagnosis.
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Affiliation(s)
- Marjorie L Pearson
- RAND Health and RAND Statistics Group, RAND, Santa Monica, CA 90407-2138, USA.
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Landheer MLEA, Therasse P, van de Velde CJH. The importance of quality assurance in surgical oncology. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2002; 28:571-602. [PMID: 12359194 DOI: 10.1053/ejso.2002.1255] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
AIMS The aims were to review the existing methods of quality assurance in surgical oncology and to determine a relationship between surgery-related factors and the variety in outcomes in the treatment of solid cancers. METHODS The literature was reviewed by searching Medline and Cancerlit databases. RESULTS Wide variations were found in virtually all tumour types. Clear evidence was found that an improvement in the quality of the surgical procedure could have major implications for the prognosis and quality of life of cancer patients. CONCLUSIONS These findings emphasize the need for strict quality control procedures in surgical oncology and might imply a considerable change in cancer treatment strategies, because the routine use of adjuvant therapies could be questioned.
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Legrand C, Sylvester R, Duchateau L, Janssen P, Therasse P. Treatment outcome studies. pitfalls in current methods and practice. Eur J Cancer 2002; 38:1173-80. [PMID: 12044502 DOI: 10.1016/s0959-8049(02)00085-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The objective of a treatment outcome study is to investigate the heterogeneity in outcome between patients according to factors other than treatment, such as country, institution or physician. Results of treatment outcome studies have already been extensively presented in the medical literature. However, no clear methodology has emerged to perform treatment outcome studies and various methods have been used. This paper reviews the different types of questions addressed in treatment outcome studies, the different methodologies and the different endpoints used. Statistical techniques are mainly descriptive including tables, estimates of survival curves, but regression models have also been used. Most of the studies use registry data, while only a few use discharge data or data available from clinical trials.
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Affiliation(s)
- C Legrand
- European Organization for Research and Treatment of Cancer, Av. E. Mounier 83, Box 11, B-1200 Brussels, Belgium.
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Engel J, Nagel G, Breuer E, Meisner C, Albert US, Strelocke K, Sauer H, Katenkamp D, Mittermayer C, Heidemann E, Schulz KD, Kunath H, Lorenz W, Hölzel D. Primary breast cancer therapy in six regions of Germany. Eur J Cancer 2002; 38:578-85. [PMID: 11872353 DOI: 10.1016/s0959-8049(01)00407-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Studies from six regions of Germany (Aachen (W1), Dresden (E1), Jena (E2), Marburg (W2), Munich (W3), and Stuttgart (C1)) have been compared to verify and assess the quality of healthcare using breast cancer as an example. All of the data collection was carried out in comprehensive cancer centres and is population-based, with the exception of C1. Classic prognostic factors and the initial treatment of 8661 women with breast cancer, diagnosed between 1996 and 1998, were examined. Primary therapy, breast conserving therapy (BCT), and the use of subsequent local radiation and/or systemic therapy (chemotherapy or hormonal therapy) were analysed. BCT was performed on 39.3-57.7% of patients. By pT-category, the proportion of BCT in the six regions were as follows: for pTis between 37.8 and 64.3%, for pT1 between 51.7 and 71.5%, for pT2 between 25.9 and 51.1%, for pT3 between 0 and 13.1% and for pT4 between 0 and 15.2%. Multivariate analyses, adjusted for age and biological factors, showed a significant influence of the treating hospital on the mastectomy rate. The use of radiotherapy after BCT (80%) was quite homogeneous in the six regions. The application of radiotherapy after mastectomy, however, varied between 10.4 and 32.2%. In all regions, for premenopausal patients, the use of adjuvant systemic therapy almost reflected the St. Gallen-Consensus recommendations. In contrast, post-menopausal women with positive lymph nodes were not always treated according to these standards. In all regions, age had an influence on the administration of treatment: elderly breast cancer patients received less BCT, less radiotherapy and less adjuvant therapy than recommended in the St. Gallen-Consensus. Feedback of the results was made available to each hospital, providing a comparative summary of patient care that could be used by the participating hospitals for self-assessment and quality-control.
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Affiliation(s)
- J Engel
- Cancer Registry of the Comprehensive Cancer Center Munich, Marchioninistrasse 15, 81377, Munich, Germany.
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Burke M, Burke KI, Boyle S, Shah K, Price AB, Zammit C. Late results of selective axillary surgery based on contact cytology in women with operable breast cancer. Br J Surg 2002; 89:341-3. [PMID: 11872060 DOI: 10.1046/j.0007-1323.2001.02028.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Interest in the possibility of intraoperative analysis of sentinel lymph nodes to select patients with operable breast cancer for immediate axillary clearance encouraged this review of a long-term experience of selective axillary surgery based on intraoperative contact cytology of conventionally sampled nodes. Survival was assessed as a potential marker for understaging. METHODS Records of 437 patients who had surgery between 1991 and 1994 were reviewed to compare rates of axillary recurrence in patients who had contact cytology only with those who had contact cytology and axillary clearance. RESULTS Axillary recurrence occurred in seven (3 per cent) of 219 patients who had negative contact cytology, three (4 per cent) of 75 patients who had positive contact cytology with axillary clearance and one (1 per cent) of 93 who had axillary clearance alone. In patients with positive contact cytology, 131 (78 per cent) of 168 positive nodes were in the sample specimen, which included all positive nodes on 19 occasions. Survival probability at 36, 72 and 96 months was 92, 87 and 84 per cent respectively for patients with negative contact cytology, and 85, 73 and 71 per cent for patients with positive cytology and axillary clearance. CONCLUSION A selective approach to axillary surgery based on intraoperative contact cytology of sampled lymph nodes gave good long-term control of axillary disease.
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Affiliation(s)
- M Burke
- Departments of Surgery and Cellular Pathology, Northwick Park Hospital, Harrow, UK.
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Abstract
To achieve optimum quality of care for women with breast cancer in the UK, uniformity of care in accordance with consensus guidelines is needed. This review highlights variations in provision of care for women with breast cancer, with particular emphasis on care received in the UK, examines differences in survival, and discusses the factors that may underlie these differences. Strong variation in treatment was identified, which appeared to affect survival significantly. These findings reinforce the need for women with breast cancer to be treated by dedicated specialists working within a multidisciplinary team to provide a high standard of care.
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O’Higgins N, Geraghty J, Barrett EJ. Evolving Structures in Surgical Oncology and The Role Of The Federation Of European Cancer Societies in Continuing Medical Education. Surg Oncol Clin N Am 2001. [DOI: 10.1016/s1055-3207(18)30028-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Rouse AM, Jolly K, Stevens AJ. Has Calman-Hine succeeded? Analysis of breast cancer procedure loads per consultant firm before and after the Calman-Hine report. Breast 2001; 10:55-7. [PMID: 14965561 DOI: 10.1054/brst.2000.0210] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The Calman-Hine report was published in the UK in April 1995. It recommended the reorganization of cancer services into high-volume specialist units. This study analyzes Health Episode Statistics from the West Midlands Region of the UK NHS in order to establish whether--for breast cancer--specialization is occurring. We believe it is. Each year since the start of our analysis (1992) the proportion of procedures performed by 'high-volume' firms increased. The number of firms undertaking breast cancer procedures fell.
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Affiliation(s)
- A M Rouse
- Department of Public Health and Epidemiology, The University of Birmingham, Birmingham, UK.
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Abstract
BACKGROUND Surgical audit is routinely conducted throughout the surgical community in order to examine practice in a peer-review environment. A national audit for breast cancer surgery has been implemented in Australia and New Zealand. It aims to standardize the way in which surgical activities are recorded. The present paper describes the development and implementation of the audit project. METHODS An audit kit including instruction manual, data dictionary and choice of two data collection instruments (paper or database) were distributed among participants. Surgeons record their patients prospectively, submit data to central office and provide feedback. RESULTS Information on 3000 breast cancer patients has been collected within the first 6 months. CONCLUSION The project has been successfully implemented and is continuing to develop. Many surgeons have incorporated the patient record forms in their routine case management activities. Comments and other submissions have been reviewed and changes incorporated into the second and subsequent releases of the kit.
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Affiliation(s)
- P Malycha
- Royal Australasian College of Surgeons, South Australian State Office, Adelaide, Australia
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Abstract
Data on postmastectomy breast reconstructive surgery were examined for 52,357 female breast cancers that were treated with mastectomy and diagnosed in geographic areas covered by the National Cancer Institute's Surveillance, Epidemiology, and End Results Program. The proportion of cancers that involved reconstruction varied in these geographic areas in each age group (under age 70 years) by a factor of about four or five, even after adjustment for stage at diagnosis, marital status, and poverty rate of county of residence at diagnosis. Studies are needed to explain the large differences in reconstruction rates by geographic area.
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Affiliation(s)
- A P Polednak
- Connecticut Tumor Registry, Connecticut Department of Public Health, Hartford 06134-0308, USA.
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Bell CM, Ma M, Campbell S, Basnett I, Pollock A, Taylor I. Methodological issues in the use of guidelines and audit to improve clinical effectiveness in breast cancer in one United Kingdom health region. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2000; 26:130-6. [PMID: 10744929 DOI: 10.1053/ejso.1999.0755] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIMS To develop a system to improve and monitor clinical performance in the management of breast cancer patients in one United Kingdom health region. DESIGN An observational study of the changes brought about by the introduction of new structures to influence clinical practice and monitor change. SETTING North Thames (East) Health region, comprising seven purchasing health authorities and 21 acute hospitals treating breast cancer. SUBJECTS The multi-disciplinary breast teams in 21 hospitals and an audit sample of 419 (28%) of the breast cancer patients diagnosed in 1992 in the region. INTERVENTIONS Evidence-based interventions for changing clinical practice: regional guidelines, senior clinicians acting as <<opinion leaders>>, audit of quality rather than cost of services, ownership of data by clinicians, confidential feed-back to participants and education. OUTCOME MEASURES Qualitative measures of organizational and behavioural change. Quantitative measures of clinical outcomes compared to guideline targets and to results from previous studies within this population. RESULTS Organizational changes included the involvement, participation of and feedback to 16 specialist surgeons and their multidisciplinary teams in 21 hospitals. Regional clinical guidelines were developed in 6 months and the dataset piloted within 9 months. The audit cycle was completed within 2 years. The pilot study led to prospective audit at the end of 2 years for all breast cancers in the region and a 15-fold increase in high quality clinical information for these patients. Changes in clinical practice between 1990 and 1992 were observed in the use of chemotherapy (up from 17-23%) and axillary surgery (up from 46-76%). CONCLUSIONS The approach used facilitated rapid change and found a balance between local involvement (essential for sustainability within a hospital setting) and regional standardization (essential for comparability across hospitals). The principles of the approach are generalized to other cancers and to other parts of the UK and abroad.
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Hébert-Croteau N, Brisson J, Latreille J, Blanchette C, Deschênes L. Variations in the treatment of early-stage breast cancer in Quebec between 1988 and 1994. CMAJ 1999; 161:951-5. [PMID: 10551190 PMCID: PMC1230703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2023] Open
Abstract
BACKGROUND The influence of organizational factors on the process and outcomes of the treatment of breast cancer has been extensively investigated. Although the quality of care is presumed to be better in larger centres, evidence is inconsistent. This study was conducted to determine whether therapies for patients with breast cancer varied according to hospital caseload. METHODS Women newly diagnosed between 1988 and 1994 with early-stage node-negative primary breast cancer were randomly selected from the Quebec tumour registry and the Quebec hospital discharge database. Data were collected from medical charts, and only women having undergone dissection of the axilla were included in the analyses. Logistic regression analysis was used to adjust for case mix and organizational variables. RESULTS The final sample included 1259 patients with node-negative stage I or II primary breast cancer. The proportion of women who underwent breast-conserving surgery increased significantly with hospital caseload (from 78.0% in hospitals admitting fewer than 25 new cases each year to 88.0% in those admitting 100 patients or more; p for trend < 0.001). This trend remained significant even after statistical adjustment for case mix and organizational factors (p for trend = 0.001). Of the 1039 women who underwent breast-conserving surgery 965 (92.9%) received radiotherapy. Use of systemic adjuvant therapy (tamoxifen or chemotherapy, or both) increased with the number of patients treated in a given centre (from 60.1% to 68.5%), but this trend disappeared after adjustment for case mix and other factors. The proportion of patients receiving systemic adjuvant therapy consistent with published consensus guidelines tended to increase with caseload for those treated in hospitals participating in multicentre clinical trials but decrease with caseload for patients in hospitals not involved in clinical research. INTERPRETATION The care of patients in Quebec with early-stage breast cancer is characterized by a high prevalence of both breast-conserving surgery and systemic adjuvant therapy. Large centres, especially those actively involved in clinical research, rapidly adopt innovative therapeutic modalities.
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Affiliation(s)
- N Hébert-Croteau
- Direction de santé publique, Régie régionale de la santé et des services sociaux de Montréal-centre, Que.
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Valentini M, Mari E, Belfiglio M, Nicolucci A. Is adjuvant tamoxifen used optimally in the treatment of breast cancer? Results of an Italian survey. Ann Oncol 1999; 10:789-93. [PMID: 10470425 DOI: 10.1023/a:1008355014886] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Institutional and physician-related factors can influence the way in which physicians interpret research results. The aim of this study was to determine what physicians know about, and their opinions of, hormone treatment in breast cancer patients, and the factors comprising their medical decision-making. MATERIALS AND METHODS A questionnaire was mailed to a random sample of physicians inquiring as to their preferences with respect to adjuvant tamoxifen, and the usual duration of the treatment applied in various clinical scenarios (according to a woman's menopausal status, the oestrogen receptor status and the stage of disease). RESULTS Of 500 physicians identified, 38% returned the questionnaire. Of the non-responders, a random sample of 60 physicians was interviewed by phone. The total number of available questionnaires was 250 (50%). About 3/4 of the doctors would prescribe tamoxifen in older ER+ women and 30%-40% in post-menopausal ER-patients, but only 2/5 would do so in younger ER+ women. The vast majority of physicians considered five years as standard for ER+ patients. Nevertheless, about 1/4 of the doctors chose a shorter treatment duration for node-negative, pre-menopausal patients. A minority of physicians used tamoxifen for longer than five years. Older clinicians were less likely to prescribe tamoxifen, particularly for low-risk patients. CONCLUSIONS According to the data of the recent EBCTG overview, an additional 20,000 lives could be saved worldwide each year if tamoxifen were given to all early breast cancer patients with hormone-sensitive disease, irrespective of age and disease stage, and for a minimum of five years. Our study, involving a representative sample of physicians practicing in Italy, shows that tamoxifen is not used optimally, with a substantial under-use in younger women and women with node-negative disease.
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Affiliation(s)
- M Valentini
- Department of Clinical Pharmacology and Epidemiology, Istituto di Ricerche Farmacologiche Mario Negri, S. Maria Imbaro, Italy
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Msellati P, Meda N, Welffens-Ekra C, Leroy V, Van de Perre P, Mandelbrot L, Dabis F. Zidovudine and reduction of vertical transmission of HIV in Africa. ANRS 049 Trial Group. Am J Public Health 1999; 89:947-8. [PMID: 10358695 PMCID: PMC1508660 DOI: 10.2105/ajph.89.6.947] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Tulloh B, Johnson B, Baker J. Breast cancer outcomes at the Strathfield Breast Centre: comment. THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF SURGERY 1999; 69:396. [PMID: 10353561 DOI: 10.1046/j.1440-1622.1999.01582.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Kricker A, Armstrong B, Smith C, Bilous M, Camaris C, Mayer A, Psarianos T. An audit of breast cancer pathology reporting in Australia in 1995. Br J Cancer 1999; 80:563-8. [PMID: 10408867 PMCID: PMC2362319 DOI: 10.1038/sj.bjc.6690392] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
To measure the quality of pathology reporting of breast cancer and establish a baseline against which future changes can be measured, we audited item completeness in breast cancer reports in Australia in 1995 before the release of specific recommendations from the Australian Cancer Network. Tumour type and size were given in reports of invasive breast cancer for 93% of women, 70% had, in addition, grade and clearance of the margins while only 28% had all recommended information. The most complete items in reports were histological type of breast cancer (99.6% of cases), tumour size (94%, 95% confidence interval (CI) 92-95) and margins of excision (87%, 95% CI 85-89). Histological grade (84%, 95% CI 82-86 of cases) and presence or absence of ductal carcinoma in situ (DCIS) (79%, 95% CI 77-81) were less complete and vessel invasion (61%, 95% CI 58-63) and changes in non-neoplastic breast tissue adjacent to the breast cancer (68%, 95% CI 66-71) the least complete. Less than half the reports of DCIS reported on tumour size (49%, 95% CI 42-57), presence or absence of necrosis (41%, 95% CI 34-49) or nuclear grade (39%, 95% CI 31-46). Around 1500 reports were identified as issued by 147 laboratories and 392 pathologists; 69% of pathologists issued fewer than two reports a month in the audit. We concluded that infrequency of reporting may have contributed to incompleteness of reporting. In addition, we found significant variation across Australian states with some indication that reporting was consistently poor in one state. The audit highlighted areas for improvement for breast cancer reporting in Australia. Research evidence suggests that multifaceted strategies are needed to assist practitioners with implementing more uniform reporting standards.
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Affiliation(s)
- A Kricker
- NHMRC National Breast Cancer Centre, NSW, Australia
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H�bert-Croteau N, Brisson J, Latreille J, Blanchette C, Desch�nes L. Compliance with consensus recommendations for the treatment of early stage breast carcinoma in elderly women. Cancer 1999. [DOI: 10.1002/(sici)1097-0142(19990301)85:5<1104::aid-cncr14>3.0.co;2-1] [Citation(s) in RCA: 160] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Grabau DA, Jensen MB, Blichert-Toft M, Andersen JA, Dyreborg U, Carstensen B, Al-Suliman NN, Graversen HP, Rose C. The importance of surgery and accurate axillary staging for survival in breast cancer. Eur J Surg Oncol 1998; 24:499-507. [PMID: 9870724 DOI: 10.1016/s0748-7983(98)93320-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
AIMS The purpose of this study was to investigate, within the context of the Danish Breast Cancer Cooperative Group (DBCG) programmes, whether a dedicated surgical approach had a significant bearing on the outcome of breast cancer treatment. METHODS From 1 January 1980 to 31 December 1990, patients below 70 years of age with operable breast cancer from Odense University Hospital (n=743) were compared with those from the rest of Denmark (denoted rest-DK) (n=15,419). All patients were treated according to nationwide DBCG guidelines and reported to the DBCG Data Centre. The potential median observation time was 11.2 years (range 6.0-16.9). Patients underwent mastectomy or breast conserving therapy, and high risk lymph-node positive patients had adjuvant systemic therapy with or without radiotherapy. RESULTS Comparing total patients series, overall survival (OS) was significantly superior in patients from Odense compared with rest-DK (P=0.02), with 10-year OSs of 62% (95% CI: 58-65%) and 56% (55-57%), respectively. In subgroups, the OS of low-risk node negative patients (protocol A) in Odense compared with rest-DK was significantly better (P=0.02); 10-year OS was 78% (73-84%) versus 72% (70-73%). Among the high-risk pre-menopausal patients (protocol B), the OS was significantly better in Odense (P=0.009); 10-year OS was 67% (60-75%) versus 53% (51-55%) in rest-DK. Post-menopausal high-risk patients (protocol C) did not differ significantly in OS between Odense and rest-DK (P=0.61). Locoregional control in the Odense series was superior compared with rest-DK. More lymph nodes were recovered and examined from the axilla in the Odense series than in rest-DK, a median of 10 vs. 6 nodes. In the Odense series, a significantly higher proportion of pre-menopausal patients had positive lymph nodes, predominantly one to three positive nodes, and subsequently a lower proportion of pre-menopausal patients had negative lymph nodes compared with rest-DK (P=0.02), indicating a more accurate staging in Odense vs. rest-DK. The survival benefit among the patients from Odense cannot be explained by stage migration alone, but seems to represent a true survival advantage. Overall mortality was significantly lower in the Odense series compared with rest-DK. Whether or not this difference could be explained by lower background mortality in the Odense series or was caused by superior treatment is discussed. CONCLUSIONS The extent of surgery seems important for locoregional tumour control and accurate axillary lymph-node staging. In combination, these might lead to superior recurrence-free and overall survival, although differences in background mortality cannot be ignored. Surgery, therefore, might represent a risk factor by itself.
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Affiliation(s)
- D A Grabau
- Department of Pathology, Oncological Research Centre, Odense University Hospital, Denmark
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