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Surgeon and Breast Unit Volume-Outcome Relationships in Breast Cancer Surgery and Treatment

McDermott, Ailbhe M. MD*; Wall, Deirdre M. BSc*; Waters, Peadar S. MD*; Cheung, Shan MPhil; Sibbering, Mark FRCS; Horgan, Kieran MCh§; Kearins, Olive MCh; Lawrence, Gill MD; Patnick, Julietta FFPH; Kerin, Michael J. MD*

doi: 10.1097/SLA.0b013e3182a66eb0
Original Articles From the ESA Proceedings

Objectives: To determine whether surgeon case volume and Unit case volume affected specific recognized key performance indicators (KPIs) of breast cancer surgical management.

Background: An increasing body of evidence suggests that a higher standard of cancer care, demonstrated by improved outcomes, is provided in high-volume units or by high-volume surgeons. The volume-outcome relationship pertaining to screen-detected breast cancers has yet to be thoroughly established and remains a pertinent issue in view of the debate surrounding breast cancer screening.

Methods: The study population comprised all women with a new screen diagnosed breast cancer between 2004–2005 and 2009–2010. Surgeons' mean annual patient volumes were calculated and grouped as very low (<5), low (5–15), medium (16–49), or high volume (>50). The effect of breast screening unit volume was also evaluated. Statistical analyses were performed using Minitab V16.0 software (State College, PA) and R V2.13.0.

Results: There were 81,416 patients aged 61 (±6.8) years treated by 682 surgeons across 82 units. There were 209 very low-, 126 low-, 295 medium-, and 51 high-volume surgeons. The proportion of patients managed by very low-, low-, medium-, and high-volume surgeons was 1.2%, 6.9%, 65.5%, and 25.7%, respectively. Patients managed by high-volume surgeons were more likely to have breast-conserving surgery (BCS) than those managed by low-volume surgeons (P < 0.001). There was a higher proportion of sentinel lymph node biopsies (SLNB) performed by high-volume surgeons in invasive cancers (P = 0.005). High-volume units performed more BCS and SLNB than low-volume units (P < 0.001 and P < 0.001, respectively).

Conclusions: Even in a setting with established quality control measures (KPIs) surgeon and unit volume have potent influences on initial patient management and treatment.

Supplemental Digital Content is Available in the Text.Volume-outcome data have been reported in the management of symptomatic breast cancer but less frequently for screen-detected tumors. We assessed whether surgeon case volume and Unit case volume affected specific recognized key performance indicators (KPIs) in initial breast cancer management and treatment. This study shows that even in a setting with established quality control measures (KPIs), surgeon and unit volume (caseload) have potent influences on initial patient surgery and treatment. Surgeon specialization in the management of screen-detected breast cancers, associated with a higher case volume, results in a measurable improvement in KPIs and increased implementation of best practice.

*Discipline of Surgery, National University of Ireland, Galway, Ireland

West Midlands Cancer Intelligence Unit, University of Birmingham, UK

Department of Surgery, Royal Derby Hospital, Derby, UK

§Department of Surgery, St James University Hospital, Leeds, UK

NHS Cancer Screening Programmes, Sheffield, UK.

Reprints: Mark Sibbering, FRCS, NHSBSP/ABS Audit Group, Association of Breast Surgery, Royal College of Surgeons of England, 35–43 Lincoln's Inn Fields, London WC2A 3PE, United Kingdom. E-mail: Mark.Sibbering@nhs.net.

Disclosure: There are no conflicts of interest for any of the authors.

Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal's Web site (www.joem.org).

© 2013 by Lippincott Williams & Wilkins.