Oncologists Question Results of Breast Cancer Treatment Study

Is bigger better? When it comes to cancer centers, results of a study published in the August 2008 issue of Annals of Surgery suggest the answer is yes. The retrospective study included nearly 25,000 women with advanced breast cancer (stages III and IV) who were treated at Florida hospitals from 1994-2000. Researchers found that women who received care at an academic medical center or teaching hospital were more likely to be alive 5 and 10 years down the road than were women treated at a community hospital. Breast cancer patients treated at teaching hospitals were also more likely than those who received care at a community hospital to receive multimodality therapy and breast-conserving surgery.

“I would tend to believe that, to some extent, this data is true,” says Anu Gupta, MD, head of Virginia-based Associates in Radiation Oncology and a member of the clinical faculty at Lombardi Comprehensive Cancer Center at Georgetown University, Washington, DC. “But, the academic centers can provide a variety of support staff and certain treatment modalities that just aren’t realistic options in a community hospital. So, I think that may be skewing some of the [study’s] data.”

Experts in breast cancer care shared their concerns with the study’s conclusions. They question whether the study’s results, which considered only community hospitals in Florida, are applicable to community hospitals nationwide.

Volume and reputation

Jack Sariego, MD, a breast cancer surgeon at Jeanes Hospital in Philadelphia, Pennsylvania, and a professor of surgery at Temple University School of Medicine, admits that, regarding surgical oncology, the prevailing wisdom is that patients receive better treatment at larger centers. He considers this perception an oversimplification, however. “The success rate tends to be a function of volume and reputation of the surgeon rather than of the treatment center,” explains Dr. Sariego, who once handled surgical oncology cases at a community hospital in rural Mississippi. “Even in a 160-bed hospital we did a large number of cancer cases and had results that were equal to or better than those at larger institutions,” he notes.

Dr. Gupta agrees and says the study is not clear on physicians’ role in offering the patients a variety of treatment options. She says that standard treatment options like chemotherapy and radiation therapy are generally available at most facilities. In addition, she points out that the study found early stage breast cancer patients did not fare better or worse in community hospitals versus large centers. “But, when you get into second and third generation treatment options, especially when we’re talking about stage III and stage IV disease, there is no clear-cut [treatment] answer.” Dr. Gupta wonders what information the community physicians addressed in this study offered their patients regarding available treatments.

Defining community hospitals

The study also does not clearly define what constitutes a “community hospital.” Christine Hodyl, MD, director of breast health services at South Nassau Communities Hospital in Long Island, New York, says that not all community hospitals are the same. A small 100-bed community hospital often does not take a multidisciplinary team approach or use the most current adjuvant chemotherapy, radiation, and hormonal treatments, factors that the study suggests account for the discrepancy in survival rates found between community hospitals and academic medical centers. Yet, South Nassau, a 450-bed community hospital, does all of these things. Dr. Hodyl explains, “On a weekly basis we come together with multiple specialists and discuss cases of newly diagnosed breast cancer. The surgeon is there, the radiation oncologist, the medical oncologist, and the radiologist. We look at the images and determine what is the best approach for each patient.” She notes that although community hospitals are not academic institutions associated with a university, many have comprehensive cancer centers that provide very good care and offer the majority of currently available therapies.

Dr. Sariego also makes the argument that newer, more progressive modalities are offered only at larger medical centers because, in many cases, “they’re not proven modalities yet. You’re not going to see some brand new chemotherapy drug which has not stood the test of time being offered at the community hospital, because that’s irresponsible. It’s going to be offered at a center where there’s a randomized trial going on to examine the effectiveness of that drug, and that’s the teaching hospitals.”

Food for thought

Dr. Sariego cautions that local or regional studies contain local biases that complicate how the results should be interpreted. In other words, the findings might be applicable only to community examined. “It’s not necessarily just a blip on the radar,” he says, “but it doesn’t mean the information is translatable nationwide.”

Despite these concerns, Dr. Gupta believes the study’s conclusions provide food for thought for oncologists. She says they should send “a clear message to anyone who practices in any form of community that some interaction needs to occur up front with the patient, especially one with advanced-stage disease. This may be your last chance to save that person.”

Ed Rabinowitz is a veteran healthcare writer and reporter. He welcomes comments at edwardr@frontiernet.net.