TABLE 5.12

Five-Year Breast Cancer Survival by Surgeon Specialty, Scotland, 1980-1988

 

Specialist Surgeon (%)

Nonspecialist Surgeon (%)

Disease

Node negative

81

77

Node positive

58

47

Age

<50

72

64

51-64

68

57

65-74

59

54

Social indicators

Affluent

72

64

Intermediate

66

58

Deprived

65

54

 

SOURCE: Gillis and Hole, 1996.

Gillis and Hole (1996) compared the survival experience of women with breast cancer diagnosed between 1980 and 1988 in western Scotland, according to whether or not their provider was a "specialist." Surgeons were characterized as specialists if they were involved in a dedicated breast clinic, organized and facilitated clinical trials, and kept separate records of patients limited to breast cancer. Such specialists provided about 25 percent of the care to the 3,786 cases. There was an absolute 9 percent difference in survival between groups at 5 years and 8 percent at 10 years. Specialty care was associated with an adjusted relative risk of death of 0.84 (C.I. 0.75-0.94). The benefit was seen for all clinical and social indicators considered (Table 5.12).

An early study by McArdle and Hole (1991) in Scotland from 1974 to 1979 found a fourfold variation in survival and surgical complications based on a surgeon's specialty volume and interest in colorectal disease or surgical oncology. Subsequent British studies have not confirmed this effect. Kingston et al. (1991) evaluated the care provided for 578 patients by 12 surgeons interested in colorectal cancer, but practicing outside academia, to university care and found no benefit from university care. Mella et al. (1997) performed a one-year audit of 3,221 patients diagnosed in 1992-1993 in Wales and Scotland. The 30-day mortality was 7.6 percent. No surgeon volume effect (using either 10 or 30 cases per year as a dichotomous variable) or specialty interest effect was noted for 30-day mortality.

A recent report from Canada compared the care of 683 patients treated by 52 surgeons for rectal cancer at five Edmonton hospitals between 1983 and 1990 (Porter et al., 1998). Five surgeons had specific fellowship training in colorectal surgery. After adjusting for known clinical factors, local recurrence and disease-specific survival were both adversely affected by being cared for by a non-specialty-trained surgeon or low-volume surgeon (fewer than three cases per year, on average). Local recurrence is an especially strong indicator of surgical technique and a much more dire (essentially untreatable) event than local recurrence in breast cancer. The relative



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