"High Volume" Breast Cancer Surgeons Have Better Outcomes

Most surgeons in the US who perform breast cancer surgeries do not do the number of them each year that has been associated with higher five-year rates of patient survival, according to a new study by researchers at the Medical College of Wisconsin. The study was published in the online edition of Cancer (August 9, 2004), a peer-reviewed journal of the American Cancer Society.

In earlier studies, US surgeons who performed 15 or more breast cancer surgeries per year and UK surgeons who performed 30 or more breast cancer surgeries per year reported significant reductions in five-year mortality rates. The Medical College research was designed to determine if US surgeons are meeting minimum volumes to achieve better results.

"We think the most important finding of the study is that very few surgeons in the United States seem to be doing the kind of volumes of breast cancer surgery that are needed to have the best outcomes," said Joan M. Neuner, MD, MPH, Medical College Assistant Professor of General Internal Medicine at the College's Center for Patient Care and Outcome Research.

Dr. Neuner and her colleagues reviewed clinical data reported by 989 surgeons to the Medicare linked tumor registry. The surgeons had operated on 8,105 Medicare patients during a two-year period from 1994 to 1995. Only six breast cancer operations were performed in two years by surgeons at the midpoint of the survey data, the authors found. Seventy-nine percent of the surgeons performed 12 or less in two years. Twenty-eight percent of surgeons performed no breast cancer operations on Medicare patients in each year of the study.

Keeping Skills Up
"There were limitations in what we could look at because surgical oncology is not a separate board-certified specialty," said Dr. Neuner. "People wanted us to have information about who is a surgical specialist in breast cancer and there just isn't that kind of information out there. So what we ended up using as a proxy for experience was total number of surgeries per year."

"What we found is that the vast majority of people who are doing breast cancer surgery are board-certified general surgeons and they are well trained to do it, but what we saw is that as they get years out from residency they're just not doing very many. So we were concerned about what that would mean in terms of keeping up their skills based on a couple of prior papers, which said that people who did a lot of breast cancer surgeries had better five-year mortality for their patients."

Breast cancer is one of the most common cancers and is now the second leading cause of death for women in the US. Significantly, the researchers found 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 dissection.

"Part of what we need to do is conduct more research," said Dr. Neuner. "We need to look at what things the high volume surgeons do that lead to better outcomes, because we don't think it's just about volume. We think there are certain things that most of the high volume surgeons do well. They may not be technical things. They may be things like coordinating well with medical oncologists who give tamoxifen routinely, or chemotherapy. We suspect that things like that, coordinated care, are very important."

More Information for Patients
Medicare patients make up about half of all breast cancer patients, Dr. Neuner said, and as a population they provide medical care data that is well recorded and relatively easy to access. And Medicare patients are a diverse group in terms of race and social and economic class, so involving them in large-scale studies of breast cancer treatment provides information of great general value because it comes from such a good cross-section of the overall population.

"A group entirely from MCW is studying Medicare patients again," said Dr. Neuner. "They're surveying them all and following up with multiple surveys over time. They're going to be asking some of the same questions, asking the patients directly as well as looking at some of the cancer registries from multiple states across the country to figure out what processes of care might be associated with better outcomes."

"At this point our advice is similar to what lots of other people including breast cancer advocacy groups say, which is, talk to your surgeon about what they're doing right now. Certainly all of the surgeons that we've talked to here are very comfortable telling you 'this is something I do a lot' or 'I'm referring you to my colleague who does a lot of that.' If it's something you're worried about asking, remember that it's a fair question and surgeons are used to it."

Dan Ullrich
HealthLink Contributing Writer

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.