Benefits of Breast Surgical Specialization

Multi-cuisine restaurants specializing in Mexican, French, Chinese and Italian fare have their place, and are fine if you don’t quite know what you feel like eating. If however you have a craving for quality Peking Duck, you are probably better served heading to the Flower Drum. In the same way, whilst there is an ongoing role for surgical generalists, if you have a suspected or confirmed breast cancer, it seems only common sense to see a specialist breast surgeon.

Evidence has consistently and repeatedly shown that patients who are treated by surgeons with a higher caseload of breast cancer patients each year, have better survival than those who are treated by surgeons who see fewer cases. This evidence reinforces the specialised nature of breast surgery. Patients treated by a specialist breast surgeon are more likely to have breast conserving surgery, and are more likely to receive adjuvant treatments such as radiotherapy.

The most specialized breast surgeons, who perform only breast surgery and no general surgery at all, such as Jane O’Brien, do not have urgent general surgical referrals competing for their time, and most keep aside sufficient urgent appointment slots for breast cancer referrals so that you can be seen promptly if you have a suspected or confirmed breast cancer. They have all their specialized infrastructure (breast care nurse, office ultrasound, breast biopsy instruments/equipment, on site radiology practice etc) based at their practice premises and most will therefore not consult out of multiple locations in the same way as general surgeons do.

What is the evidence for the affect of specialization on survival ?

Evidence linking individual surgeon caseload to improved survival in breast cancer began emerging in the mid 1990s yet somewhat surprisingly women with breast cancer continue, almost 15 years later, to see low caseload general surgeons. This is at least in part due to the fact that the evidence is not widely reported or publicised, an explanation supported by a 2007 study finding that the most informed women, who actively choose their breast surgeon, are most likely to see a high volume surgeon. The same study found that women with more education and higher incomes are more likely to report selecting their surgeon based on reputation, which correlated with high caseload. Another 2007 study similarly observed clear differences among patients cared for by high-, medium-, and low –volume surgeons, in terms of sociodemographic characteristics.

Sainsbury, as far back as 1995, on examining differences in survival as a function of consultant caseload demonstrated poorer results amongst those surgeons treating less than 30 new cases of breast cancer per year compared to those treating more than 30 new cases per year. Lancet 1995.

The five year survival rate was 9% higher and the 10 year survival 8% higher for patients with breast cancer treated by specialist breast surgeons in Scotland. The benefit of specialist care was apparent for all age groups, for small and large tumours, and for tumours that did and did not affect the nodes and was consistent across all socioeconomic categories. British Medical Journal 1996.

A Yorkshire study in 2003 revealed that breast cancer patients operated on by specialists did better than those treated by surgeons with fewer breast cancer patients. Reporting their results in the British Journal of Cancer, Cancer Research UK scientists found that patients operated on by surgeons with an annual breast cancer caseload of more than 50 patients had a 68 per cent chance of survival after five years. The survival rate dropped to 60 per cent among patients whose surgeons performed fewer than 10 breast cancer operations a year. So if a specialist surgeon operates on 100 women, 8 more women will survive at least 5 years than if all 100 of them had been operated on by a less experienced colleague. The study was based on more than 11,000 patients over a five-year period. The figures for survival are much lower than would be expected currently in Australia as they were based on patients treated between 1989 and 1994 in the United Kingdom, where breast cancer survival was at that time poor compared to other Western countries such as the USA and Australia.

A British unit analyzed their breast cancer outcome between 1990-1992 and 1993-1996, that is before and after the advent of surgical subspecialization. After subspecialization disease free survival improved from 70 to 79 % and the all recurrence rate fell from 22 to 12% at 3 years. British Journal of Surgery 2000.

Similar results were found locally, in a Western Australian study published in 2005. The outcomes for all women diagnosed with invasive breast cancer in Western Australia during 1989, 1994 and 1999 were assessed, and the results compared for surgeons who treat 20 or more cases per year with those of surgeons who treat fewer. Women treated by high caseload surgeons were more likely to retain their breast (53.3% vs. 36.7%), have adjuvant radiotherapy (50.0% vs. 30.6%), and be alive after 4 years (1989, 86% vs. 82%; 1994, 89% vs. 84%; 1999, 90% vs. 79%,). The results were felt also to confirm that women treated by high caseload surgeons have better outcomes. The Breast 2005.

An American study also found similar results. Treatment by a specialist resulted in a 33% reduction in the risk of death at 5 years. Specialists achieved an 86% 5-year survival, compared with 79% for non-specialists. The data supports a role for a surgeon’s case volume on long-term survival after surgery for breast cancer. Surgeons who performed >15 breast cancer surgeries per year achieved a 5-year survival of 84%, compared with the 84% of surgeons who performed 1 to 5 breast cancer surgeries per year, who had a 5-year survival of 75%. Annals of Surgical Oncology 2003.

Similarly, in Taiwan, of the 13,360 breast cancer resection patients in a 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 (≤44). Breast Cancer 2008.

Three possible explanations for an effect of surgeon specialization on long-term outcome include (1) pure volume effects (specialists tend to perform more of a specific type of surgery and therefore may have better results), (2) pure surgical skill (specialist breast surgeons have advanced training and are therefore better trained to perform breast cancer surgery and may perform a technically superior operation), or (3) more appropriate use of adjuvant therapies (specialist breast surgeons are trained not only in surgical technique, but also in the biology of cancer and the role of radiation and systemic therapies in cancer treatment and therefore may be more likely to refer patients appropriately).

What other surgeon characteristics are associated with high caseload ?

A study by Medical College of Wisconsin researchers in Milwaukee found that many U.S. surgeons do not perform sufficient numbers of breast cancer surgeries to obtain optimum results. “We were surprised to find that despite sufficient evidence associating low surgical volumes and lack of experience with poor outcomes, the majority of breast cancer surgeries in women are done by surgeons who do not specialize in cancer or breast cancer surgery,” said Joan M. Neuner, M.D., the study’s author. It is likely that only approximately 10% of patients in the United States are treated by surgeons who performing at least 30 annual operations.

Although moderately higher surgical volume was found for certain types of surgeons (female, middle aged, urban location), both overall volumes and surgeon subgroup volumes were well below the volume of procedures associated with better survival. Significantly, the researchers confirmed that patients of physicians with the higher patient volumes were more likely to receive surgical care more consistent with standard of care, such as hormone receptor testing, breast conserving surgery, and lymph node staging. Surgeon characteristics ofage and female gender were associated with higher volumes of breast cancer surgery. Cancer 2004.

Are women seeing the most experienced breast cancer surgeons?

Women who take more control over choosing their breast cancer surgeon are more likely to be treated by more experienced breast surgeons compared to women who were referred by another doctor or their health plan, according to a study led by researchers at the University of Michigan Comprehensive Cancer Centre. The study looked at 1,844 women recently diagnosed with breast cancer in the Detroit and Los Angeles metropolitan areas. The women were surveyed about how the breast surgeon was selected, with choices such as “I was referred by another doctor,” “I chose this surgeon because of his or her reputation” or “I wanted a surgeon who practiced near my home.” Based on the answers, patients were categorized as being referred to their surgeon or selecting their surgeon based on reputation or proximity.

Here’s what the study found:

• 15% selected their surgeon from the health plan list
• 63% selected their surgeon based upon referral from another doctor
• 25% selected their surgeon based upon their reputation
• 15% selected their surgeon based upon the hospital where they worked
• 13% selected their surgeon based upon the recommendation of family or friends
• 9% selected their surgeon based upon proximity to home

Respondents were free to cite more than one answer.

Nearly two-thirds of the patients said they were referred to their surgeon by another doctor, with another 15 percent referred by their health plan. About a quarter chose their surgeon based on reputation. Women with more education and higher incomes were more likely to report selecting their surgeon based on reputation. About one-third of the women were treated by a high-volume surgeon – a surgeon who devoted more than half of his or her practice to breast surgery. Women who selected their surgeon based on reputation were more likely to be treated by a high-volume surgeon.

The patients in the study most likely to experience the best outcomes were those who selected their surgeon based upon their “reputation.” Why? As it turned out, these patients were more likely to get treatment from surgeons that did a high volume of breast cancer procedures. Journal of Clinical Oncology 2007.

Click here to read more about Article (Rich, young, educated women get better breast cancer care than poor, older women)

Despite the evidence for a survival disadvantage, some patients who are involved in surgeon choice opt to go to a low-volume hospital, nearer to their place of residence, according to a French study. One hundred fifty-six (17%) patients underwent an operation in low-volume, 414 (44%) in moderate-volume, and 362 (39%) in high-volume hospitals. Patients in low-volume hospitals were more likely to be >70 years old and to have an elementary education level. Surgery 2008.

Although the relationship between higher surgeon volume and lower mortality has been described for breast cancer, selection bias has not been rigorously evaluated. Treatment by a high-volume surgeon was associated with younger patient age, white race, less comorbidity, and residence in a more affluent zip code in a US study, raising the possibility of selection bias as a potential explanatory factor. Arch Int Med 2007.

What are the implications for rural Australia ?

The issue was examined in the Medical Journal of Australia in August 2006.

Australia is a vast country with a widely dispersed population. A third of Australians live outside major cities; nearly half of these live in rural and remote areas. Because of evidence that better surgical outcomes are achieved with increased specialisation and higher provider volumes (which tend to be available in larger city centres), a trend towards urban centralisation of surgical services has developed. High-volume centres are usually large metropolitan hospitals, which are likely to have superior infrastructure and support services; are better able to offer improved postoperative care; and are more likely to adhere to established processes of care leading to better patient outcomes. In such high-volume centres, there are also potential cost savings flowing from fewer postoperative complications and higher use of resources.Support of volume-based referral initiatives is particularly strong in the field of cancer surgery, with one meta-analysis recommending the centralisation of most, if not all, oncological procedures.

But what is the rural resident’s perspective on urban centralisation of surgical services? Many rural patients choose to have their surgery with familiar and trusted physicians close to home, work, friends and family. Many struggle with separation from family and friends, time off work, the need to travel, and costs of accommodation. General practitioners are happier referring patients for elective surgery at a familiar hospital which is convenient geographically. Waiting times for appointments can also be shorter in a rural setting compared with a metropolitan centre of excellence.

A number of studies have demonstrated rural patients’ desires to have their treatment locally. Some women choose mastectomy by their local surgeon rather than travel for radiotherapy after breast conservation treatment for breast cancer. Others requiring radiotherapy for breast cancer have shown a willingness to accept a delay to treatment of several weeks rather than leave their home town for earlier therapy.

The decision to undergo surgery in a low-volume centre is ultimately the patient’s, after a fully informed and frank discussion with his or her surgeon about the risks and benefits. Individual surgeons should be able to quote their own outcome figures and complication rates for comparison with published standards to facilitate this. Rather than compete for patients and operations, small-volume and large-volume centres should cooperate: team members from both centres should participate in multidisciplinary meetings to plan patient care, and selected patients should be treated at either the smaller or larger centre after consideration of who is most likely to derive the most benefit at each location. This would spread the workload, maintain everyone’s skills and knowledge, and provide the maximum benefit for the most people. MJA 2006.

Patient satisfaction with treatment of breast cancer: does surgeon specialization matter ?

“Yes” according to a study published in 2007. Experience and practice setting vary greatly among surgeons who treat breast cancer patients. The association between surgeon specialization (percentage of practice devoted to breast disease) with four domains of patient satisfaction: (1) the surgical decision, (2) decision-making process, (3) surgeon-patient relationship, and (4) surgeon-patient communication, adjusting for patient and surgeon demographics and disease stage were examined.

In this sample, 34.5% of patients were treated by surgeons who devoted less than 30% (low volume) of their practice to breast disease, 32.5% by surgeons who devoted 30% to 60% (medium volume) of their practice to breast disease, and 33.0% by surgeons who devoted more than 60% (high volume) of their practice to breast disease. Compared to patients treated by low-volume surgeons, patients treated by higher volume surgeons were more satisfied with the decision-making process.

The potential mechanisms that may explain the correlation between surgeon specialization in breast surgery and patient satisfaction are unclear. It is possible that surgeons who specialize in breast surgery may have better interpersonal skills developed through accumulated experience and greater interest in treatment of breast cancer patients. It is also possible that specialized breast surgeons may have better technical outcomes compared with those of non specialized surgeons. Their patients may not require reoperation as frequently, or may have superior aesthetic outcomes after surgery. Additionally, patients of specialized breast surgeons may report higher levels of satisfaction resulting from attributes of the surgeon’s practice setting. For example, availability of support staff such as breast care nurses, informational materials, on-site diagnostic and therapeutic resources, and logistic ease of care may be important predictors of patient satisfaction. Finally, previous work has demonstrated that patients who actively selected their surgeon were more likely to be treated by a more experienced surgeon. These patients may have different initial expectations about the  communication or the relationship with their surgeon, which could influence their perspectives measured after treatment. In this study, patients who selected their surgeon by reputation were more likely to report satisfaction with the relationship and communication with their surgeon. Journal of Clinical Oncology 2007.

Journal Watch : Annals of Surgery, May 2009.

Surgical Specialization and Patient Outcome

As outline above, there is great interest in the degree to which surgical specialization affects outcomes. Prior discussions regarding positive volume-outcome relationships have debated whether “practice makes perfect” or whether better surgeons get more referrals and therefore have higher volumes. This raises two relevant questions. Does specialization itself lead to reduced mortality, or do better surgeons become specialists?

This issue was re-examined in a study and the accompanying editorial published in Annals of Surgery, May 2009. The authors in this study proposed that either “better surgeons become specialists” or that “the specialist seems to be good at ‘everything’ they do.” The authors postulate that those “surgeons who are ‘good’ to begin with, and thus will be good at everything they do, choose or are selected to be become specialists,” and that the specialist seems good at everything they do.

The differences in outcomes between specialist and general surgeons may be explained in several ways, including the effect of high volume, systematic differences in choice of treatment and the contribution of other healthcare professionals. Specialist surgeons are more likely to perform higher volumes of select procedures. Four studies however that have examined the independent contributions of specialization and volume of surgery have demonstrated that when volume discrepancies between specialist and general surgeons were controlled for, the benefit from specialization was still apparent. These findings suggest that the benefit of specialization cannot be explained simply by ‘practice makes perfect’. High surgeon volume and specialization are independently associated with improved patient outcome.

In a simplistic sense, the specialist appears good at “everything” they do: something important about being a specialist spills over into all their cases. Two possible contributing explanations, which are not exclusive, might be most significant: “Selection bias” versus “Acquired ability.” Under the selection bias theory, surgeons who are “good” to begin with, or have the innate ability to be good, and thus who will be good at everything they do, choose or are selected to become specialists. Under the acquired ability theory, something about the process of specializing in certain procedures (the fund of knowledge or the learning processes that lead to a special fund of knowledge, the attention to detail in diagnosis/surgery/management, certain patient management processes or the attention to processes in general, the process of skills acquisition or the development of generalizable technical skills, etc) leads to generally better patient outcomes spilling across all cases.

The unintended consequences of the drive to specialization must however be carefully considered from a public health standpoint. This is why countries are faced with a serious projected shortage of general surgeons, surgeons able and willing to take emergency calls and surgeons able and willing to work in rural areas. What will be the ultimate impact from the move to specializations on public health?

Take home message for patients: The proposed underlying explanations are probably not of great relevance to the individual breast cancer patient; the fact is that overwhelming evidence supports the finding that outcomes are better for breast cancer patients treated by high volume specialist breast surgeons compared to those treated by lower volume general surgeons.