Surgeon workload and survival from breast cancer.

Despite evidence of improving mortality from breast cancer in the UK (Peto et al, 2000), published studies suggest that survival from breast cancer in the UK compares unfavourably with many European countries (Quinn et al, 1998; Berrino et al, 1999). Wide variations in the management of breast cancer patients have been reported in the UK (Chouillet et al, 1994; Sainsbury et al, 1995b; Richards et al, 1996), and variable care is thought to contribute to the relatively poor performance in the UK (Sant et al, 1998). Greater specialisation in the management of breast cancer, with the formation of multidisciplinary teams, gradually followed the implementation of breast screening 10–12 years ago. This was further stimulated by a major national policy initiative in cancer in 1995 (Calman and Hine, 1995), and by the subsequent publication of the Improving Outcomes Guidance for breast cancer services in 1996 (Cancer Guidance, 1996). Whether better outcomes in breast cancer are directly related to the concentration of breast cancer patients in the hands of specialist surgeons, and the multidisciplinary teams in which they work, has been a subject of growing interest. Although significant outcome benefits from higher caseloads for complex radical cancer surgery, such as in pancreatic or prostate cancer, have been reported, the evidence for caseload outcome relationships in cancers requiring low-risk surgery, like breast cancer, is based on far fewer studies (Hillner et al, 2000). In this study, our aim was to follow-up an earlier investigation on the effect of surgeon workload on survival of breast cancer patients (Sainsbury et al, 1995a), and to establish whether the original finding, supportive of a volume outcome relationship, has remained the case in a more recent time period. We also wished to examine how surgeons' breast cancer workloads have changed over time and to assess whether differences in outcome could be explained by case-mix and treatment regimes employed.