On Referral Patterns for Patients With Breast Cancer

In this issue of the Journal of Clinical Oncology, Katz et al describe mechanisms by which newly diagnosed breast cancer patients report selecting their surgeons in two large cities. They found that 54% of women reported that they were referred to their surgeon by a clinician or health plan, 22% reported they selfselected a surgeon despite having been referred by their clinician or health plan, and 20% self-selected their surgeons without a referral. Patients who selected their own surgeons were more likely to be treated by high volume providers in an American College of Surgeon–approved cancer program or National Cancer Institute– designated cancer center. The authors raise concerns for women who are directed by clinician referrals and health plans to surgeons with lower volume and not necessarily associated with cancer programs. Their concern rests on the increasing evidence of lower mortality in association with high volume institutions and high volume surgeons across multiple clinical conditions, including cancer. Luft developed the practice makes perfect hypothesis as a model to explain how higher volume might improve outcomes. High volume allows more training, development of stronger skills, and more experience. In addition, high volume institutions and providers gain production efficiencies, allowing for economies of scale and savings when purchasing costly equipment and specialized services. Improved survival and efficiencies in operations motivate more referrals, resulting in even more patient volume. Over time, substantial evidence supporting lower mortality rates for patients receiving complex medical care and high-risk surgical procedures in institutions managing high volumes of patients have been noted across multiple studies, countries, clinical conditions, procedures, and settings. Birkmeyer et al and colleagues have shown consistently higher mortality rates in lowervolume hospitals for six cardiovascular and eight cancer surgical procedures. Begg and colleagues showed postoperative deaths and morbidities were higher after radical prostatectomy for patients associated with lower volume hospitals and surgeons. Both studies showed the magnitude of the effect varied by surgical procedure, even after adjustment for case mix. Both studies, as well as a myriad of others across countries, clinical conditions, and settings have found similar results for high-risk surgical procedures. Hynes and colleagues found that higher-volume hospitals treating breast cancer had lower postoperative lengths of stay and readmission rates, which are both indicators of lower costs and better quality. Hillner et al found the association between outcomes and provider volume was much stronger for cancers requiring high-risk procedures, such as pancreatic, esophageal, and gastric cancers, and hepatic resection, than lower-risk procedures, including breast cancer. With these data in mind, policy makers across the years have struggled to define actions to respond to the accumulating evidence that higher volume predicts lower mortality. How and for which conditions should actions be implemented? Some, like the Leapfrog Group, a coalition of key stakeholders, have advocated selective referral in urban centers for high-risk procedures. But, as Epstein has described, many unresolved issues remain. Is there an exact cut point to define high enough volume? How stringent should adherence be? What kinds of data are needed to set that threshold? Should insurers, providers, or patients decide circumstances when that threshold should be overridden? The data presented by Katz et al show that women who self-selected their surgeons, as compared with being directed by their clinicians or health plan, were significantly more likely to be white, highly educated, affluent, and were more likely to have had second opinions. They report that self-selection of surgeons was not associated with patient age, tumor characteristics, or geographic site. For the clinical area described by Katz and colleagues, we need to ask how, if at all, the data supporting a volume-outcome link for breast cancer, a condition not considered as high-risk in terms of short-term mortality as other procedures, should influence referral patterns for breast cancer patients. Optimal outcomes for breast cancer patients require more than good initial surgical interventions. Multiple interventions across disciplines and time are needed. As demonstrated in the recent American Society of Clinical Oncology–funded National Initiative for Cancer Care Quality (NICCQ), multiple domains of quality contribute to assuring that patients receive the care needed to optimize their outcomes. Patients need access to high-quality pathology services, as well as adjuvant treatment with chemotherapy, radiation, and hormonal therapies as a supplement to initial surgical procedures. Furthermore, coordination and continuity of care are needed to assure symptoms are managed, comorbid conditions are addressed, and treatments are continued. To date, little is known about how volume influences these domains of process. The Institute of Medicine has described six aims considered essential for the redesign of health care: care should be safe, effective, patient-centered, timely, efficient, and equitable. While they might have focused on structural characteristics to improve quality, they selected more specific targets such as processes more proximate to patients and their outcomes. Recommendations for JOURNAL OF CLINICAL ONCOLOGY E D I T O R I A L VOLUME 25 NUMBER 3 JANUARY 2