Breast cancer patients who received their initial treatment in teaching hospitals had better survival than those who received their treatment in community hospitals, according to a new study published today in the Canadian Medical Association Journal.
Using 1991 data, the study found that five-year survival for Ontario women with small cancers who were initially treated at a teaching hospital was 93% compared to 89% for women treated at a community hospital.
There are a number of possible explanations for these differences, but the authors concluded that the breast cancer surgery itself and the skills of the surgeon likely do not contribute to the variation.
"The study suggests that a comprehensive approach to cancer care including diagnostic, surgical, systemic, radiation and support services, can improve survival," said Dr. Vivek Goel, one of the study's authors and Chair of the University of Toronto's Department of Health Administration.
"There is no reason for women to change where they have their breast cancer surgery," said Dr. Denny DePetrillo, a surgical oncologist and Provincial Coordinator of Cancer Care Ontario's Surgical Oncology Network. "Community surgeons have the necessary skills to perform breast cancer surgery."
The study's authors believe that the differences in survival are attributable to the organization of breast cancer care at teaching hospitals, including the delivery of comprehensive, multidisciplinary care, that was not as common in community hospitals 10 years ago.
Since the study was initiated, there have been clinical practice and system level changes that should have reduced practice variations between teaching and community hospitals.
For example, many community hospitals have launched comprehensive breast cancer centres similar to what existed in teaching hospitals 10 years ago.
Since the early-1990's, links also have been established between regional cancer centres and community hospitals to ensure that cancer patients have access to the most appropriate care. Currently, 102 Ontario hospitals are formally affiliated with Cancer Care Ontario.
Over the last decade, new knowledge and the development and use of practice guidelines also likely have contributed to a reduction in the variation in practices. For example, it is now standard practice for women with early-stage breast cancer to be considered for systemic therapy as well as radiation treatment.
Additionally, in 1997, Cancer Care Ontario established the Surgical Oncology Network. The network is a surgeon led initiative made up of both community and specialty surgeons, aimed at better integrating cancer surgery with the rest of the cancer system.
Research done in other jurisdictions where similar practice and system changes have occurred has demonstrated improvements in both processes of care and breast cancer outcomes.
"Given this research, and based on my experience as a breast cancer researcher and an oncologist who treats breast cancer patients, I believe that that the changes that have occurred in Ontario over the past 10 years likely have reduced the variation in survival shown in the study," said Dr. Carol Sawka, one of the study's authors and CEO of the Toronto-Sunnybrook Regional Cancer Centre.
Breast cancer has one of the highest survival rates of all cancers. Overall breast cancer survival, including women with advanced disease, is 81%. Breast cancer survival has been steadily increasing since the mid-1980's.
In 2000, approximately 7,500 Ontario women were diagnosed with breast cancer and 2,100 died from the disease. While breast cancer is the most common female cancer, lung cancer kills more women annually