Concerns raised about surgeons performing occasional breast cancer operations

A leading cancer expert has expressed concern about the link between hospitals carrying out low numbers of breast cancer operations and disproportionately high readmission rates.

Professor Ian Fentiman from London's Guy's Hospital made his comments in IJCP, the International Journal of Clinical Practice, after researchers from Korea discovered that 95 per cent of breast cancer surgery readmissions were from hospitals performing less than 100 procedures a year.

"The growing volume of evidence that surgical expertise has a significant impact on outcome is becoming increasingly hard to ignore" says Professor Fentiman. "The days of the occasional breast cancer surgeon are coming to an end."

The Korean team looked at the records of 1,351 women in 24 hospitals and found that just over one per cent were readmitted because of complications within 30 days of undergoing surgery.

There was a strong link between the volume of procedures a hospital carried out and the readmission rate. 71 per cent of the women had been treated at hospitals performing less than 50 breast cancer operations a year and a further 24 per cent had been treated at hospitals performing less than 100 procedures a year.

All the patients were registered with the National Cancer Registry in Korea and the number of patients having breast cancer surgery at low, medium and high volume hospitals was 35, 32 and 33 per cent respectively.

"The results of this study confirm that hospital volume has an impact on the outcome of breast cancer operations and implies the need for setting an optimised number of cancer-related surgeries for each hospital as part of an effort to improve patient outcome" says one of the paper's authors, Professor Seok-Jun Yoon from Korea University in Seoul.

Professor Fentiman agrees that there is an increasingly well-documented link between surgical volume and outcome.

In his accompanying editorial to the paper, he says that the Korean study adds to the growing body of evidence that breast cancer surgery is not for the occasional operator.

He points to a 2005 Swiss study that showed that women who had surgery in low volume hospitals had a three-fold risk of drying of breast cancer.

Similar results were reported by the West of Scotland Cancer Surveillance Unit ten years ago when they analysed the revival rates of nearly 4,000 patients and found that the 10-year survival rate for women operated on by specialist surgeons was eight per cent higher.

Another large study of breast cancer cases treated in Yorkshire between 1989 and 1994 showed that women treated by surgeons performing less than ten breast cancer operations a year faced an increased death rate of 15 per cent.

He adds that studies of other surgical procedures, including prostate cancer and operations on the pancreas and oesophagus, have also found significant differences between low and high volume institutions.

"Poor surgical technique has been linked to more complications and deaths" says Professor Fentiman. "This may become apparent immediately after complex surgery on vital organs such as the heart, but for breast cancer patients unnecessary deaths from inadequate procedures can take years to manifest.

"Although workload and hence experience is a major determinant of outcome, it is expertise that it most important. However, there is normally a close correlation between the number of procedures a surgeon carries out and his or her level of expertise.

"Quality assurance in breast cancer surgery will assume even greater importance as new techniques, which could improve patient outcomes and reduce hospital stays, become more widely used" he adds.

"It is essential that these specialist procedures are carried out by surgeons who perform sufficient numbers of breast cancer operations to develop and maintain the level of expertise needed."

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