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Does specialized care mean better care?

Canadian Medical Association Journal

It has been known for some time that there are marked variations in survival after diagnosis with breast cancer. Chances of survival hinge mainly on the specific cellular characteristics of tumours and the stage of the disease at diagnosis. However, when controlling for these factors, women with seemingly similar tumours at the same stage of the disease experience different disease-free and survival rates.

In this issue of the Canadian Medical Association Journal Dr. Vivek Goel and colleagues report on efforts to determine if initial treatment of breast cancer at specialized centres (teaching hospitals) makes any difference in survival. They identified 938 women with early stage breast cancer (breast cancer limited to the breast) from the records of the Ontario Cancer Registry and followed these women for 5 years. Women who were initially treated in community hospitals had a 5-year survival rate of 88.7% versus 92.5% among women who were initially treated in teaching hospitals. These differences were more marked among women with very small tumours at initial staging (less than 2cm), who experienced a 53% relative reduction in risk of death if they were initially managed at a teaching hospital as opposed to a community hospital.

"This study suggests that treatment at teaching centres may be advantageous for women with small tumours," write the authors. "There is a need to identify whether these results can be attributed to differences in specific processes of care."

In a related commentary, Dr. Robert Grilli, an international expert on this topic, points out that this paper is "just the latest in a number of papers exploring the impact of specialization on care for cancer patients." Grilli adds that "overall, the results (show) that being cared for by specialists (or at specialized centres) is associated with better survival. He also suggests it is time to move from research that quantifies the effects of specialization to more qualitative approaches that provide greater understanding of what this concept means in terms of working relationships among health professionals.


Breast cancer survival by teaching status of the initial treating hospital - R. Chaudhry, V. Goel, C. Sawka

Specialization and cancer: words with too many meanings should be handled with care - R. Grilli Dr. Grilli, Agenzi Sanitaria Regionale, Bologna, Italy 39-051-283231. email--

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