To conduct a systematic review of the literature on the volume-outcome relationship for the surgical treatment of breast cancer with consideration of the methodological quality of the available evidence and to perform a meta-analysis on the studies of considered good quality.
A systematic search was done to identify all articles examining the effects of hospital or surgeon volume on clinical outcome of the surgical treatment of breast cancer. Reviews, opinion articles and surveys were excluded. All articles were critically appraised on methodological quality and risk of bias. After strict inclusion, meta-analysis assuming a random effects model was done to estimate the effect of higher hospital or surgeon volume on patient outcome.
We found 12 studies of good methodological quality which could be included for meta-analysis. The results showed a significant association between high volume providers and an improved survival. The association is the most robust for surgeon volume (HR 0.80 (0.71–0.90) and RR 0.85 (0.80–0.90). In addition there is an effect of hospital volume on the in-hospital mortality, although the mortality was very low (0.1–0.2%). Results of meta-analysis were heterogeneous. Sensitivity analysis showed a larger effect size for studies also adjusting for comorbidity for both studies on hospital and surgeon volume. The data were not suggestive for publication bias.
The results show that survival after breast cancer surgery is significantly associated with high volume providers.
To read this article in full you will need to make a payment
Purchase one-time access:Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
One-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:Subscribe to European Journal of Surgical Oncology
Already a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
- Survival outcome of care by specialist surgeons in breast cancer: a study of 3786 patients in the west of Scotland.BMJ. 1996; 312: 145-148
- Influence of clinician workload and patterns of treatment on survival from breast cancer.Lancet. 1995; 345: 1265-1270
- Directing surgical quality improvement initiatives: comparison of perioperative mortality and long-term survival for cancer surgery.J Clin Oncol. 2008; 26: 4626-4633
- Hospital volume and surgical mortality in the United States.N Engl J Med. 2002; 346: 1128-1137
- Surgical volume and mortality in the United States.N Engl J Med. 2003; 349: 2117-2127
- Hospital volume and late survival after cancer surgery.Ann Surg. 2007; 245: 777-783
- Influence of hospital characteristics on operative death and survival of patients after major cancer surgery in Ontario.Can J Surg. 2006; 49: 251-258
- Differences in operative mortality between high- and low-volume hospitals in Ontario for 5 major surgical procedures: estimating the number of lives potentially saved through regionalization.CMAJ. 2003; 168: 1409-1414
- High-volume versus low-volume for esophageal resections for cancer: the essential role of case-mix adjustments based on clinical data.Ann Surg Oncol. 2008; 15: 80-87
- Misclassification of hospital volume with surveillance, epidemiology, and end results medicare data.Surg Innov. 2007; 14: 192-198
- Measuring inconsistency in meta-analyses.BMJ. 2003; 327: 557-560
- Bias in meta-analysis detected by a simple, graphical test.BMJ. 1997; 315: 629-634
- Effects of specialisation on treatment and outcomes in screen-detected breast cancers in Wales: cohort study.Br J Cancer. 2006; 94: 36-42
- Survival after breast cancer treatment: the impact of provider volume.J Eval Clin Pract. 2007; 13: 749-757
- Does high surgeon and hospital surgical volume raise the five-year survival rate for breast cancer? A population-based study.Breast Cancer Res Treat. 2008; 110: 349-356
- Five-year survival from breast cancer in Western Australia over a decade.Breast. 2007; 16: 375-381
- Relationship between number of breast cancer operations performed and 5-year survival after treatment for early-stage breast cancer.Am J Public Health. 2007; 97: 539-544
- High hospital volume is associated with better outcomes for breast cancer surgery: analysis of 233,247 patients.World J Surg. 2005; 29 ([discussion 99–1000]): 994-999
- Are many community hospitals undertreating breast cancer?: lessons from 24,834 patients.Ann Surg. 2008; 248: 154-162
- Investigating the correlation between hospital of primary treatment and the survival of women with breast cancer.Cancer. 2005; 104: 1343-1348
- Exploring the surgeon volume-outcome relationship among women with breast cancer.Arch Intern Med. 2007; 167: 1958-1963
- Breast cancer: do specialists make a difference?.Ann Surg Oncol. 2003; 10: 606-615
- Surgeon workload and survival from breast cancer.Br J Cancer. 2003; 89: 487-491
- The relation between surgical volume and mortality: an exploration of causal factors and alternative models.Med Care. 1980; 18: 940-959
- Should operations be regionalized? The empirical relation between surgical volume and mortality.N Engl J Med. 1979; 301: 1364-1369
- Does it matter where you live? Treatment variation for breast cancer in Yorkshire. The Yorkshire Breast Cancer Group.Br J Cancer. 1995; 71: 1275-1278
- Variation in management of small invasive breast cancers detected on screening in the former South East Thames region: observational study.Br Med J. 1997; 315: 1266-1272
- Physician practice volume and alternative surgical treatment for breast cancer in Florida.Health Serv Res. 2001; 36: 166-179
- Provider case volume and outcome in the evaluation and treatment of patients with mammogram-detected breast carcinoma.Cancer. 2002; 95: 704-712
- Predictors of breast conservation therapy: size is not all that matters.Cancer. 2005; 103: 892-899
- EUSOMA accreditation of breast units.Eur J Cancer. 2006; 42: 1331-1337
- The requirements of a specialised breast unit.EUSOMA, Florence2010
- The impact of the Calman-Hine report on the processes and outcomes of care for Yorkshire’s breast cancer patients.Ann Oncol. 2008; 19: 284-291
- Volume- or outcome-based referral to improve quality of care for esophageal cancer surgery in The Netherlands.J Surg Oncol. 2009; 99: 481-487
- The case against volume as a measure of quality of surgical care.World J Surg. 2005; 29: 1222-1229
- The volume-outcome debate revisited.Am Surg. 2006; 72: 1038-1042
Accepted: June 9, 2010
☆Study performed by the ‘Quality of cancer care’ taskforce of the Signalling Committee Cancer of the Dutch Cancer Society. (the committees full report is available on www.kwfkankerbestrijding.nl)
© 2010 Elsevier Ltd. Published by Elsevier Inc. All rights reserved.