lable at ScienceDirect

The Breast 19 (2010) 297e302

Contents lists avai

The Breast

journal homepage: www.elsevier .com/brst

Original Article

Challenges and economics of private breast cancer surgery practice

Lisa Bailey a,b,*

aBay Area Breast Surgeons, Inc., 3300 Webster Street, Suite 212, Oakland, CA 94609, USAbMedical Director, Carol Ann Read Breast Health Center, Alta Bates Summit Medical Director, 3100 Summit Street, Oakland, CA 94609, USA

a r t i c l e i n f o

Article history:Available online 13 April 2010

Keywords:Breast cancerOutcomesCoordinated careQualityBreast-focused surgeonCase volume

* Bay Area Breast Surgeons, Inc., 3300 Webster St94609, USA. Tel.: þ1 510 835 9900; fax: þ1 510 835 9

E-mail address: lbailey@babsurgeons.com.

0960-9776/$ e see front matter � 2010 Elsevier Ltd.doi:10.1016/j.breast.2010.03.012

a b s t r a c t

The role of the breast cancer surgeon has changed from one with performance of one operation, toa position in which the surgeon is the patient’s initial contact, leader of a multidisciplinary team, theclinical leader who ensures that the patient receives the most appropriate breast cancer treatment andthen also receives follow up and surveillance services. Breast conservation rates, patient satisfactionrates, clear margins, use of oncoplastic surgical techniques, appropriate referral to other consultants,clinical trial referral, and survival rates are all higher when patients are cared for by breast-focusedsurgeons. This new role requires greater time both before and after surgery to provide the properplanning and care for these patients. Women with breast cancer should have access to these dedicatedbreast-focused surgeons. Recognition of this expanding responsibility and reimbursement for this timeand expertise is needed so that women with breast cancer can be offered the highest quality of care.

� 2010 Elsevier Ltd. All rights reserved.

Introduction

Breast cancer surgery has changed significantly over the pastfew decades. The role of the surgeon has changed from one lonephysician performing one operation (mastectomy) on a diseaseoriginally viewed as a singular type in nature. The surgeon is, today,so much more than just the provider who does an operation toremove the breast cancer. The surgeon is now the breast cancerpatient’s initial contact, leader of a multidisciplinary team, navi-gating the patient through the many diagnostic and therapeuticmodalities comprising the modern management of breast cancer,and, then, after the initial stages of treatment are complete, theclinical leader who ensures that the patient receives follow up andsurveillance services. However, insurance agencies have shownlittle recognition of this expanded, time-consuming role, nor havethey acknowledged the studies that show breast cancer patientshave improved outcomes and survival when they receive their carefrom surgeons who dedicate their practice to breast surgery.

Breast surgery past

For the prior years well in to the 1970’s, it was the norm forwomen to be admitted to the hospital the night before surgery fora palpable breast lump. Few breast abnormalities were identified

reet, Suite 212, Oakland, CA909.

All rights reserved.

on mammography film as screening mammograms were rarelyperformed. Preoperative needle biopsies were not performed, sothe nature of the mass was unknown. All women signed consentforms for “possible mastectomy,” though approximately 80% of themasses being removedwere benign. Thewomen going through thisprocess did not know how many breasts would remain uponleaving the operating room. On occasion, their husbands wereasked for permission for a mastectomy to be performed, while thewoman was asleep and unable to give her own consent. Thesurgeons performed open biopsies of the tumor; the pathology wasdetermined by a frozen section analysis; and, if the diagnosis wascancer, mastectomy was completed during the same operation.Breast reconstruction was rarely offered.

The diagnosis of DCIS was seldom identified pathologically, andthe vast majority of the breast cancers were invasive cancers thatwere palpable and frequently large. Radical surgery and radiationwere the only treatments available prior to 1970. Pathology reportswere brief, often identifying Invasive Mammary Carcinoma orAdenocarcinoma as the diagnosis with no other details offered inthe report.

Breast surgery present

Breast cancer surgery has changed significantly since the earlierdays. Most women today have the breast cancer diagnosed becauseof a mammographic abnormality, before the mass is palpable. Mostbreast cancer diagnoses are made with a core needle biopsy ratherthan with surgery, and biomarkers such as estrogen and proges-terone receptors are often known from that core tissue. The

L. Bailey / The Breast 19 (2010) 297e302298

majority of womenwhose breast cancers are detected by screeningmammogram are diagnosed at Stage I, or with DCIS even beforeinvasive disease is found. This may partially explain the decreasingnumbers of invasive carcinomas being diagnosed. Patients andtheir surgeons have more information from the pathology reportthat is now recommended to be a synoptic report with informationon many different aspects of the cancer type, size, grade, lymphaticor vascular invasion, margins of resection, lymph node status, andbiomarkers. The biomarkers now routinely reported are ER, PR, andHer-2/neu, and sometimes others are included such as Ki-67, DNAanalysis, etc.

Patients have more choices with respect to surgery, includingbreast conservation vs. mastectomy, sentinel node biopsy withpossible axillary node dissection, immediate vs. delayed expanderor autologous reconstruction, contralateral reduction forsymmetry, neoadjuvant chemotherapy or hormonal therapy, andvarying radiation therapy options. Clinical trials may be availablefor patients to participate in, including surgical, systemic neo-adjuvant or adjuvant therapy, and radiation therapy trials.

Surgeons are now expected to read the mammograms, ultra-sounds, and MRIs, and to provide the patient with a completeconsultation regarding the information available about thepatient’s disease and its management. Proper planning of thesurgery is required if the patient is going to have a good canceroperation as well as a good cosmetic result. Evaluation of the breastand axilla prior to surgery is helpful in determining whether thepatient is a candidate for surgery as the first treatment, or if neo-adjuvant therapy would be a better option for the patient.Consultation with a plastic surgeon, a medical oncologist, and/ora fertility specialist must be thought of at the time of the initialsurgical consultation to prevent delay of the patient’s treatmentand offer her the most complete options available.

The mammograms are often reviewed with the patient, anda lengthy education session is held at the first consultation, withadditional planning meetings scheduled as needed. Telephone callsand email questions are frequent, as the patient is trying tounderstand this new diagnosis and the medical language and logicthat accompany this process. The question ofMRI is considered. Thepathology report is reviewed in detail and each aspect of the reportis discussed so that the patient can understand her disease processbetter. Often, the films are reviewed with the radiologist to assist inoperative planning. The pathology slides may also be reviewedwith the pathologist. The working stage of the disease is calculated.She and her family are understandably frightened, and thesurgeon’s discussions not only clarify the information about hercancer, but also help her to understand the risk to her future, andthe steps to be taken to care for her.

The surgery frequently involves much more time than in thepast, with oncoplastic procedures being employed to improve thecosmetic result, sentinel node biopsies being performed to reducethe risk of unnecessary axillary lymph node dissection, andworking with a plastic surgeon for contralateral reduction forsymmetry or immediate reconstruction after skin sparing or nipplesparing mastectomies. Ultrasound and/or x-ray of the specimen toevaluate the margins and accuracy of the resection adds time to theoperation but can reduce the need for re-excision.

Once the surgery has been performed, the patient returns to thesurgeon to not only have her wounds checked, but she thenappropriately wants to know the results of the pathology and thesurgeons’ recommendations for additional treatment. Discussion ofeach aspect of the pathology report is then provided, and recom-mendations for systemic and local therapies are made.

In many communities, a multidisciplinary board will discuss thepatient’s information, and make follow-up recommendations. Thesurgeon then calls the patient with the results of that

multidisciplinary conference. The surgeon’s staff makes multiplephone calls to obtain all needed records for the initial surgicalconsultation, authorization for tests and surgery, and to assist thepatient with additional consultations, spending considerable timefaxing records to those multiple consultants. The staff time andoffice time for the surgeon are considerably more than are neededfor the frequent general surgery procedures such as hernia repair,cholecystectomy, or appendectomy.

Anatomy of a breast cancer surgery consultation

A 75-year-old woman came in for consultation regarding herrecent breast cancer diagnosis. She brought her mammograms andcore biopsy slides from an outside institution, as well as copies ofher breast imaging and pathology reports. Though referred by herprimary care physician, no information about the patient’s generalhealthwas sent with the referral, requiring the office staff to call thereferring doctor’s office and request the needed medication andproblem lists. The staff requested these reports prior to theconsultation, but several phone calls were needed.

The biomarkers were performed on the core biopsy material,but not included in the initial paperwork, so additional phone callsto pathology were made to be sure that these later reports wereavailable for the consultation. The patient is sent the paperworkneeded for the consultation including the medical history intakeform and insurance information. Patients are usually quite nervousas expected and, with some frequency, will gather all of therequestedmaterials, only to forget to bring it, requiring later reviewby the surgeon after the initial consultation. The surgeon some-times can review the breast images online before the consultation ifthe films are in digital format and at an institution where thesurgeon has the appropriate access to film review.

At the initial consultation, the history recorded on the intakeform was reviewed with the patient, and a physical examinationwas performed. As part of the physical examination, ultrasoundexamination of the primary breast cancer area and the axilla wasperformed to best understand the patient’s cancer stage, and beginthe thinking about planning her surgery.

The patient, her husband, and their sonwere invited to the officefor a long discussion. She recorded the consultation to review againat her leisure. The mammograms were reviewed with the patient,and the findings explained. The patient already had a copy of herpathology report, and the details of this synoptic report are dis-cussed line by line. The object was to assist the patient in under-standing as much as was known about her individual cancer. Oncethis part of the consultation was complete, then a discussionregarding the options of therapy ensued. This discussion includedoverview of the surgical options for the breast ewere lumpectomyand radiation possible, or would mastectomy be the only surgicaloption or one of two choices, or would neoadjuvant chemotherapyor hormonal therapy be considered?

In this patient’s case, breast conservation was consideredpossible and reasonable, and her preference as well. We discussedoncoplastic breast surgery techniques and breast symmetry. Wealso discussed the varying options of radiation therapy and the prosand cons of each modality, side effects, and timing with respect tothe other therapies. We discussed the potential systemic therapies,again including the pros and cons of each option, and discussedinformation about gene array evaluationwithMammaprint� and orOncotype Dx� and the usefulness of this testing. Sentinel nodebiopsy and axillary node dissection were discussed including therationale, technique, lymphedema risk, and the newer concept ofreverse axillary mapping was included in the discussion. Addi-tionally, the patient was given information about recovery timing,possible complications, consideration of other breast cancer

L. Bailey / The Breast 19 (2010) 297e302 299

consultations, consideration of whether a breast MRI would beperformed, as well as the patient’s general health and any need foradditional testing or consultations such as with their PCP orcardiologist, etc. She was offered information on a clinical trialavailable to her.

This initial consultation required almost two hours of time,following thepreparationprior to the consultations. Amultiple pageletter was sent to her referring physician regarding all of this infor-mation, including an estimation of the current clinical stage ofdisease. Subsequently, the patient did have a breast MRI performed,and then surgerywasplanned to includea secondnoduleadjacent tothe known cancer. Prior to surgery, she returned to the office threetimes to discuss her case further and to ask additional questions,once with the surgeon and twice with the nurse practitioner.

She successfully had a lumpectomy and sentinel node biopsyperformed. Preoperative wire localization and bracketing wereperformed to include the additional nodule seen on MRI, andultrasound was utilized intra-operatively to assure adequatemargins of resection, in addition to mammography to evaluate thesurgery specimen, including removal of the clip and both wires.Additional time was spent to perform a hemi-batwing oncoplasticprocedure and closure, so that the patient would have the bestcosmetic result. A sentinel node biopsywas performedwith reverseaxillary mapping, and intra-operative pathology evaluation withtouch prep analysis.

During her first postoperative visit, her pathology report wasavailable. After assuring that she was healing well, and instructiongiven to her regarding postoperative stretching exercises, thepathology report was reviewed in detail. The discussion includedthe risk of the breast cancer to the patient, an analysis of theeffectiveness of the surgery, and consideration of the need foradditional testing. Recommendations for medical and radiationoncology consultations were made, as well as potential expecta-tions from these consultations based on the findings of the finalpathology report. Subsequently, the patient has returned fouradditional times. These visits were partially for postoperativeassessment, but also largely because the patient requested morediscussion time to better understand her pathology report andpotential adjuvant therapies. Her case was discussed at the weeklymultidisciplinary breast conference. An Oncotype Dx� test wasrequested, which required not only that the requesting order befilled out, but also the paperwork sent by her Blue Cross insuranceplan to justify the request. She also utilized e-mail on at least fiveoccasions to get additional questions answered; discuss themedical oncology recommendation; discuss the breast cancermultidisciplinary conference recommendations; and to requestinformation on other resources such as support groups, nutritionrecommendations, etc. The office staff faxed her completed recordsto each oncology specialist, which was required before they wouldmake an appointment to see the patient.

Patient centered breast cancer care

The Institute of Medicine (IOM) recommended six aims of thehealth care system, and these certainly apply to the care of womenwith breast cancer.1,2

1. Patient-centeredness e respectful and responsive care guidedby individual preferences, needs, and values.

2. Effectivenesse providing services to thosewho can benefit, andrefraining from providing to those who will likely not benefit.

3. Efficiency e best practices to avoid waste.4. Equity e care that does not vary in quality.5. Timely e reduce wait times; promote timely, coordinated care.6. Safety e avoid injury and harm.

Who performs breast surgery?

Many surgeons consider the amount of time required for theeducation and care of breast cancer patients to be burdensome.Surgeons have a phrase, the “talk-to-cut ratio”, and breast surgery isoften considered to have too much talking time and not enough“cut time”, or time in surgery. The surgeons that specialize in breastcancer are thosewho are dedicated to the education of womenwithbreast cancer, and willing to spend the time needed to help thesewomen through the process. Breast surgeons, whose practices arededicated to the care of women with breast cancer, have anorientation in line with the IOM recommendations noted above.The interest in quality measures, as introduced by the NationalQuality Forum (NQF) and applied by the Commission on Cancer,3

and the Mastery of Breast Surgery project of the AmericanSociety of Breast Surgeons (ASBS),4 and other authors5e8 highlightsthe interest and importance in ensuring a high quality of care forwomen with breast cancer.

Breast surgery has indeed changed. There is a significantlyincreased amount of information that surgeonsmust knowand alsoimpart to their patients. The quality and complexity of the surgeriesperformed are considerably more than in the past, and detailedpostoperative discussions with physicians are rightly expected bythe patients. The surgeon should be up to date not only on newersurgical techniques and information, but should also keep up todate on all other aspects of breast cancer systemic and regionaltherapies. A team approach with multidisciplinary review of eachbreast cancer has been identified as important in the overall care ofthe breast cancer patient and improvement of outcomes. This timespent with other specialists is valuable not only for the particularbreast cancer patient discussed, but also brings knowledge ofother’s specialties, and enhances best practices and outcomes.9,10

Care management is often determined and sometimes changed asa consequence of the breast cancer tumor board determinations.11

The extra time and expertise needed to provide this level of care,is often poorly compensated or uncompensated. There has been norecognition of the major changes in the role of the breast cancersurgeon. Furthermore, there has been no acknowledgement on thepart of payers about the body of knowledge showing improvedoutcomes for breast cancer patients when they are treated bysurgeons who perform a high caseload of breast cancer surgeries.Phone calls and e-mail interactions are not well compensated, ifthey are paid for at all. Surgeons may cut back the amount of timespent in educating women before and after the surgery, and inoffering the coordination of care that provides the higher quality ofcare as well as patient satisfaction. Surgeons may cut back on timespent in lengthy explanation to patients, preferring to give themreadingmaterial instead of quality time. Theymay also begin to relyon other oncology specialists to educate their patients. Time spentevaluating opportunities to consider neoadjuvant therapy for largertumors and adequate work-up of additional lesions are often lostwhen less time is taken to evaluate an individual breast cancer case.

Data shows that surgical programs do not offer adequatenumbers of breast cancer cases to residents to adequately trainthem before they enter private practice, unless the resident goes onto a breast surgery or surgical oncology fellowship.12,13 In addition,sentinel node biopsy success rates are associated with a highervolume of breast cancer cases.14e16 Most general surgeons performmultiple other procedures with higher reimbursement rates andless required office time. This enhances their ability to performgreater numbers of higher paying procedures.

Fifty percent of general surgeons perform a low volume ofbreast surgery. One study estimated that only approximately 10% ofbreast cancer cases in patients in the US are treated by surgeonswho perform at least 30 breast cancer operations per year, as seen

Table 1Breast cancer e surgeon volume.

Author Year No. of surgeons Surgeon volume

Porter17 2004 519 42% performed< 2 breast cancer cases/month76% of surgeons practice< 25% breast surgery

Neuner et al.18 2004 987 Medicare 2-year medicare volume for breast cancer surgeons was 6, and 79% ofphysicians performed �12 operationsw50% of patients were care for by doctors who performed �12 operations/2 years

Waljee et al.19 2007 318 34.5% of patients cared for by physicians< 30% is breast surgery32.5% of patients cared for by physicians 30e60% practice is breast surgery33.% patients cared for by physicians> 60% practice is breast surgery

Luther et al.20 2001 1320 42% of the physicians performed< 2 breast cancer surgeries/yearMikeljevic et al.21 2003 Mean annual workload< 10 new patients e 6% of breast cancer patients

Mean annual workload 10e29 new patients e 21% of breast cancer patientsMean annual workload 30e49 new patients e 21% of breast cancer patientsMean annual workload> 50 new patients e 52% of breast cancer patients

McKee et al.26 2002 125 50% of breast cancer patients treated by low-volume surgeons

L. Bailey / The Breast 19 (2010) 297e302300

in Table 1.17e21,26 Nevertheless, a Canadian survey17 of surgeonsshowed that those surveyed thought that all surgeons shouldperform breast procedures.

There is data showing that outcomes for breast cancer patientsare improved when they are cared for by surgeons who do a highervolume of breast cancer surgery. Patients who were cared for bysurgeonswith high volumes of breast cancer procedures had higherpatient satisfaction in the surgical decision making process, and inthe surgeonepatient communicationprocess.19 Theyaremore likelyto be offered breast conservation,with reported breast conservationrates of 39e45% for low-volume surgeons vs. 55e64% for higher-volume surgeons.18,20,22e30,41 Patients cared for by surgeons treatinghigh volumes of breast cancer patients are also more likely to beoffered oncoplastic breast surgery techniques or breast symmetryoperations,31e33 breast reconstruction,17,28,33e35,41 and clinical trialreferral.36

Several studies, as shown in Table 2, significantly show a higher5-year survival rate for breast cancer patients treated by high-volume surgeons.21,37e40,43,44,45,46e51 In one study the differencewas a 5-year survival rate of 77.3% for surgeons with high breastcancer surgery volumes vs. 69.5% for patients cared for by surgeonsperforming a low-volume of breast cancer cases, and another studyshowed a difference of 68% vs. 60%, respectively. Some of thesedifferences likely reflect that high-volume surgeons adhere torecommended care guidelines, referral for adjuvant systemic andradiation therapy, and multidisciplinary discussions of patientcare.18,21,25,48,50,57,59,60,62 High-volume surgeons also have bettersurgical techniques including improved axillary surgery, decreasedpercentage of involved or close margins of resection, and are morelikely to perform re-excision for positive margins in breastconservation surgery, leading to lower local recurrence rates of thebreast cancer.39,40,45e48,50,52,57e59,62 These important aspects of thepatient’s care likely are responsible for the survival differences seenin patients cared for by surgeons with breast-focused practices.Similar statistics are also true for patients cared for in high volumevs. low volume hospitals.30,38,42,51,54e56,61,63,64 However, theseimproved outcomes are not recognized by insurers by ensuring

Table 2Surgeon volume e breast cancer survival.

Author Year Survival

Low volume surgeons

Mikeljevic et al.21 2003 60%Golledge et al.47 2000 70%Chen et al.38 2008 5 yr survival 69.5%� 44 cases 3 yeaKingsmore et al.48 2004 1.37 Hazard ratio

access of their enrollees to these breast-focused surgeons,53 or byincreasing compensation for better performance.

The payment for breast surgery, as seen in Table 3, which ispoorly compensated when compared to other kinds of surgery, hasa 90-day global fee. Therefore, the several discussions and e-mailswith the previously described patient to review in detail herpathology report, tell her of her tumor’s status and risk to herfuture, and make recommendations for adjuvant therapy areuncompensated care. There has been no recognition of the amountof time and expertise needed to provide the highest quality of carefor breast cancer patients, or any recognition of the data showingbetter patient outcomes and survival.

There are, in addition, some additional challenges that requireconsiderable more surgeon time and care so that the patient willhave the best outcome possible from the breast cancer treatment.Some patients have psychosocial issues including denial of the riskof their disease to their health and welfare; poor coping mecha-nisms; poor social and physical support in their lives. Some patientshave significant co-morbidities that interfere with their ability tohave the optimal breast cancer treatment, or, at the very least, causedelays in their care. Some patients have language barriers, culturalbarriers, or lack of insurance that interferes with their ability to geta timely diagnosis and adequate care for their breast cancer diag-nosis. Some insurers initially deny treatments and testing thatrequire the surgeon to take time to call the insurance company andexplain the necessity of the recommended care. Any of thesechallenges adds to the complexity of the case management of thecare of the breast cancer patient. The surgeon becomes primarycare giver during this time pre-operatively and post-operatively, inaddition to performing the surgical procedure.

A recent Colloquium, sponsored by the American Society ofBreast Disease, and funded by Susan G. Komen for the Cure, entitledEnsuring Optimal Interdisciplinary Breast Care in the United Statesexamined the areas of Early Detection and Diagnosis, Local-Regional Treatment, and Systemic Treatment.65 Multiple gaps inbreast cancer carewere identified in each of these areas. These gapsaffect a woman’s care and outcome from her breast cancer

High volume surgeons

68%75%

rs 76.9% 45e200 cases/3 yrs 77.3% (>201 cases/3 years1.00 Hazard ratio

Table 3Medicare payment fee schedule.

Procedure CPTcode

Medicarepayment range

Medicare paymentOakland and Berkeley area

Globalfee period

Comments

Partial mastectomy 19301 $525.33e$776.47 $635.60 90 days Postoperative time, often considerable, to explainresults and recommend care is not compensated

Sentinel node biopsy 38525 $312.82e$487.16 $433.99 90 days When combined with partial or simple mastectomy,this is paid at 50% of the stated charges

Mastectomy, simple/total 19303 $800.54e$1204.84 $982.61 90 days Postoperative time, often considerable, to explainresults and recommend care is not compensated

Colonoscopy 45378 $188.54e$281.10 $231.11 0 days No follow-up is needed if no biopsy is donePlacement of percutaneousgastrointestinal tube

49441 $211.30e$349.32 $283.90 10 days Minimal post-op care

Appendectomy, laparoscopic 44970 $437.43e$727.26 $596.48 90 days 1e2 Short post-op visits for wound checks onlyLaparoscopic cholecystectomy 47562 $544.99e$906.08 $743.45 90 days 1e2 short post-op visits for wound checks onlyInguinal hernia repair 49525 $417.24e$693.32 $570.85 90 days 1e2 Short post-op visits for wound checks onlyPartial colectomy 44140 $998.81e$1427.81 $1339.14 90 days Inpatient care is needed, but minimal in-office care

(1e2 short visits)

L. Bailey / The Breast 19 (2010) 297e302 301

diagnosis and treatment. As the first consultant a woman withbreast cancer usually sees, the surgeonmust be aware of all aspectsof breast cancer care and the overall details that are important toensuring the highest quality of care. The surgeon does not simplyperform the operation, but is also the first educator and coordinatorof a woman’s breast cancer care.

In England, the Calman-Hine report called “A Policy FrameworkFor Commissioning Cancer Services,” was published in April 1995,in response to varying treatments and outcomes for cancer patientsin the United Kingdom.66 This report recommended significantreform of the United Kingdom’s cancer services, to improveoutcomes and reduce inequities in the National Health Servicecancer care. The primary recommendation was to concentrate thecare of cancer patients within site-specialized multidisciplinaryteams. The reports showing the outcomes by implementing theserecommendations are variable. However, where multidisciplinaryteams had been established and specialist care for breast cancerhad been implemented, there were quality improvements in areassuch as adequate axillary node excision, recording of ER status, anduse of hormonal therapy in ER positive patients.24,55,46,67e70

In Germany, nationwide voluntary breast center certification,and a collaborative network of breast centers has improved theindicators from report times between 2003 and 2007 as follows:preoperative diagnosis of breast cancer before diagnosis (58% in2003 to 88% in 2007), appropriate endocrine therapy in hormonereceptor positive tumors (27e93%), appropriate radiation therapyafter breast conserving surgery (20e79%), and appropriate radio-therapy after mastectomy (8e65%).71,72

Recommendations

Women around the globe with a diagnosis of breast cancershould have the highest quality of care available to them. Currentlyin the United States, that is not always the case. There is ampleevidence that the surgical care and outcomes of breast cancerpatients is improved when they are cared for by breast-focusedsurgeons who perform a high volume of breast surgery. In addition,these surgeons are the first part of a breast cancer team, andtherefore have a significant effect on the patient’s total care.

Women with breast cancer should be offered the informationand tools to help them make informed choices about their care. Ifthe short term and long-term outcomes of their care are superiorwhen patients are cared for by higher volume, breast efocusedsurgeons, women should be able to readily identify and have accessto those surgeons. The insurance companies andMedicare have theinformation and could easily assist their patient clients in obtaininga higher quality of care.

In addition, the insurers should consider higher payment forsurgeons who can demonstrate a higher level in quality of care fortheir patients. Re-excision rates, patient satisfaction rates, and thequality of care measures recommended by the American College ofSurgeons would be good starting points. Payment should berestructured to eliminate the 90-day global fee so that surgeons arecompensated for the consultation time needed after the surgery toreview the final pathology with their patients. Improved compen-sation for the individual procedures is needed, as is the recognitionthat excellent breast surgery is just as complicated other complexcases.

Breast cancer surgeons are the first care partner on the medicalteam that patients encounter. Clearly, information, recommenda-tions, and surgical knowledge determine the course of treatmentfor breast cancer patients. This critical role needs to be recognized,emphasized and adequately compensated so that all women withbreast cancer have the opportunity for the highest quality of careand potentially better outcomes and survival rates.

Conflicts of interest

None declared.

References

1. Rose C, Stoval E, Ganz PA, Desch C, Hewitt M. Cancer quality alliance: blueprintfor a better cancer system. CA Cancer J Clin 2008;58:266e92.

2. La Fargue M, Coleman C. In search of excellence: exploring the economics ofbreast care. Semin Breast Dis 2008;11:113e5. doi:10.1053/j.sembd.2009.04.003.

3. National Quality Forum (NQF). NQF Endorsed Commission on Cancer (CoC)measures for quality of cancer care for breast and colorectal cancers. Availablefrom: http://www.facs.org/cancer/qualitymeasures.html. [accessed February20, 2010].

4. The American Society of Breast Surgeons. Mastery of breast surgery pilotprogram. Available from: http://www.breastsurgeons.org/mastery/index.php[accessed December 15, 2009].

5. McCahill LE, Privetts A, James T, et al. Quality measures for breast cancersurgery: initial validation of feasibility and assessment of variation amongsurgeons. Arch Surg 2009;144:455e62.

6. Rutgers EJ. Guidelines to assure quality in breast cancer surgery. Eur J SurgOncol 2005;31:568e76. doi:10.1016/j.ejso.2005.02.008.

7. Yermilov I, Maggard MA. Defining quality of care for breast cancer: clinicalchallenges. Semin Breast Dis 2007;10:121e7. doi:10.1053/j.sembd.2007.10.011.

8. Birido N, Geraghty JG. Quality control in breast cancer surgery. Eur J Surg Oncol2005;31:577e86. doi:10.1016/j.ejso.2005.02.009.

9. Cady B. Interdisciplinary comprehensive breast tumor boards: their role in thecomprehensive management of contemporary breast cancer. Semin Breast Dis2008;11:4e8. doi:10.1053/j.sembd.2008.04.001.

10. Tabár L, Chen TH, Yen AM, Dean PB. Detection, diagnosis, and treatment ofearly breast cancer requires creative interdisciplinary teamwork. Semin BreastDis 2005;8:4e9. doi:10.1053/j.sembd.2006.03.006.

11. Newman EA. Changes in surgical management resulting from case review ata breast cancer multidisciplinary tumor board. Cancer 2006;107:2346e51.

L. Bailey / The Breast 19 (2010) 297e302302

12. Pass HA, Klimberg SV, Copeland EM. Are “breast-focused” surgeons morecompetent? Ann Surg Oncol 2008;15:953e5.

13. Ritchie Jr WP. Invited commentary: comment from American Board of Surgery.Surgery 2002;131:205e9.

14. Dupont E, Cox C, Shivers S, et al. Learning curves and breast cancer lymphaticmapping: institutional volume index. J Surg Res 2001;97:92e6.

15. Johnson JM, Orr RK, Moline SR. Institutional learning curve for sentinel nodebiopsy at a community teaching hospital. Am Surg 2001;67:1030e3.

16. Cox CE, Salud CJ, Cantor A, et al. Learning curves for breast cancer sentinellymph node mapping based on surgical volume analysis. J Am Coll Surg2001;193:593e600.

17. Porter GA, McMulkin-Tait H. Practice patterns in breast cancer surgery:Canadian perspective. World J Surg 2004;28:80e6.

18. Neuner JM, Gilligan MA, Sparapani R, Laud PW, Haggstrom D, Nattinger AB.Decentralization of breast cancer surgery in the United States. Cancer2004;101:1323e9.

19. Waljee JF, Hawley S, Alderman AK, Morrow M, Katz SJ. Patient satisfaction withtreatment of breast cancer: does surgeon specialization matter? J Clin Oncol2007;25:3694e8.

20. Luther SL, Studnicki J. Physician practice volume and alternative surgicaltreatment for breast cancer in Florida. Health Serv Res 2001;36:166e79.

21. Mikeljevic SJ, Haward RA, Johnston C, Sainbury R, Forman D. Surgeon workloadand survival from breast cancer. Br J Cancer 2003;89:487e91.

22. Opatt D, Morrow M, Hawley S, Schwartz K, Janz NK, Katz SJ. Conflicts indecision-making for breast cancer surgery. Ann Surg Oncol 2007;14:2463e9.

23. Hershman DL, Buono D, Jacobson JS, et al. Surgeon characteristics and use ofbreast conservation surgery in women with early breast cancer. Ann Surg2009;249:828e33.

24. Richards MA, Wolfe CD, Tilling K, Barton J, Bourne HM, Gregory WM. Variationin the management and survival of women under 50 years with breast cancerin the South East Thames region. Br J Cancer 1996;73:751e7.

25. Sainsbury R, Rider L, Smith A, MacAdam A, The Yorkshire Breast Cancer Group.Does it matter where you live?: treatment variation for breast cancer inYorkshire. Br J Cancer 1995;71:1275e8.

26. McKee MD, Cropp MD, Hyland A, Watroba N, Mckinley B, Edge SB. Providercase volume and outcome in the evaluation and treatment of patients withmammogram-detected breast carcinoma. Cancer 2002;95:704e12.

27. Morrow M, Jagsi R, Alderman AK, et al. Surgeon recommendations and receiptof mastectomy for treatment of breast cancer. JAMA 2009;302:1551e6.

28. Hawley ST, Hofer TP, Janz NK, et al. Correlates of between-surgeon variation inbreast cancer treatments. Med Care 2006;44:609e16.

29. Nattinger AB, Goodwin JS. Geographic and hospital variation in the manage-ment of older women with breast cancer. Cancer Control 1994;1:334e8.

30. Hiotis K, Ye W, Sposto R, Skinner KA. Predictors of breast conservation therapy:size is not all that matters. Cancer 2005;103:892e9.

31. Nahabedian MY. Managing the opposite breast: contralateral symmetryprocedures. Cancer J 2008;14:258e63.

32. Regano S, Hernanz F, Ortega E, Redondo-Figuero C, Gomez-Fleitas M. Onco-plastic techniques extend breast-conserving surgery to patients with neo-adjuvant chemotherapy response unfit for conventional techniques. WorldJ Surg 2009;33:2082e6.

33. Kollias J, Davies G, Bochner MA, Gill PG. Clinical impact of oncoplastic surgeryin a specialist breast practice. ANZ J Surg 2008;78:225e6.

34. Alderman AK, Hawley ST, Waljee J, Morrow M, Katz SJ. Correlated of referralpractices of general surgeons to plastic surgeons for mastectomy reconstruc-tion. Cancer 2007;109:1715e20.

35. Hofer TP, Hawley ST, Katz SJ. Does it matter where you go for breast cancersurgery? J Clin Oncol 2009;27:15s (suppl; abstr 6504).

36. Scroen AT, Brenin DR. Clinical trial priorities among surgeons caring for breastcancer patients. Am J Surg 2008;195:474e80.

37. Nattinger AB, Laud PW, Sparapani RA, Zhang X, Neuner JM, Gilligan MA.Exploring the surgeon volume outcome relationship among women withbreast cancer. Arch Intern Med 2007;167:1958e63.

38. Chen CS, Liu TC, Lin HC, Lien YC. Does high surgeon and hospital surgicalvolume raise the five-year survival rate for breast cancer? a population-basedstudy. Breast Cancer Res Treat 2008;110:349e56.

39. Allgood PC, Bachmann MO. Effects of specialization on treatment and outcomesin screen-detected breast cancers in Wales: cohort study. Br J Cancer2006;94:36e42.

40. Zork NM, Komenaka IK, Pennington Jr RE, et al. The effect of dedicated breastsurgeons on the short-termoutcomes inbreast cancer.Ann Surg2008;248:280e5.

41. Hawley ST, Hofer TP, Janz NK, et al. Correlates of between-surgeon variation inbreast cancer treatments. Med Care 2006;44:607e8.

42. Gilligan MA, Neuner J, Zhang X, et al. Relationship between number of breastcancer operations performed and 5-year survival after treatment for early-stage breast cancer. Am J Public Health 2007;97:539e44.

43. Gillis CR, Hole DJ. Survival outcome of care by specialist surgeons in breastcancer: a study of 3786 patients in the west of Scotland. BMJ 1996;312:145e8.

44. Skinner KA, Helsper JT, Deapen D, et al. Breast cancer: do specialists makea difference? Ann Surg Oncol 2003;10:606e15.

45. Morris E, Haward RA, Gilthorpe MS, Craigs C, Forman D. The impact of theCalman-Hine report on the processes and outcomes of care for Yorkshire’sbreast cancer patients. Ann Oncol 2008;19:284e9.

46. Monaghan P, Murray L, Donnelly M, McCarron P, Spence R, Gavin A. Breastcancer services e a population-based study of service reorganization. J PublicHealth (Oxf) 2005;27(2):171e5.

47. Golledge J, Wiggins JE, Callam MJ. Effect of surgical subspecialization on breastcancer outcome. Br J Surg 2000;87:1420e5.

48. Kingsmore D, Hole D, Gillis C. Why does specialist treatment of breast cancerimprove survival? The role of surgical management. Br J Cancer2004;90:1920e5.

49. Kingsmore D, Ssemwogerere A, Hole D, Gillis C. Specialization and breastcancer survival in the screening era. Br J Cancer 2003;88:1708e12.

50. Hershman DL, Buaono D, McBride RB, et al. Surgeon characteristics and receiptof adjuvant radiotherapy in women with breast cancer. J Natl Cancer Inst2008;100:199e206.

51. McCarthy M, Datta P, Sherlaw-Johnson C, Coleman M, Rachet B. Is theperformance of cancer services influenced more by hospital factors or byspecialization? J Public Health (Oxf) 2008;30:69e74.

52. Gort M, Broekhuis M, Otter R, Klazinga NS. Improvement of breast practice inearly breast cancer: actionable surgeon and hospital factors. Breast Cancer ResTreat 2007;102:219e26.

53. Katz SJ, Hofer TP, Hawley S, et al. Patterns and correlates of patient referral tosurgeons for treatment of breast cancer. J Clin Oncol 2007;25:271e6.

54. Guller U, Safford S, Pietrobon R, Heberer M, Oertli D, Jain NB. High hospitalvolume is associated with better outcomes for breast cancer surgery: analysisof 233,247 patients. World J Surg 2005;29:994e9.

55. Bouche G, Migeot V, Mathoulin-Pelissier S, Salamon R, Ingrand P. Breast cancersurgery: do all patients want to go to high-volume hospitals? Surgery2008;14:699e705.

56. Ma M, Bell J, Campbell S, Basmett I, Pollock A, Taylor I. Breast cancermanagement: is volume related to quality? Clinical Advisory Panel. Br J Cancer1997;75:1652e9.

57. Staradub VL, Rademaker AW, Morrow M. Factors influencing outcomes forbreast conservation therapy of mammographically detected malignancies. J AmColl Surg 2003;196:518e24.

58. Gilligan MA, Neuner J, Sparapani R, Laud PW, Nattinger AB. Surgeon charac-teristics and variation in treatment for early-stage breast cancer. Arch Surg2007;142:17e22.

59. Sainsbury R, Haward B, Rider L, Johnston C, Round C. Influence of clinicianworkload and patterns of treatment in survival from breast cancer. Lancet1995;345:1265e70.

60. Katz SJ, Hawley ST, Morrow M, Coordinating Cancer Care. Patient and practicemanagement processes among surgeons who treat breast cancer. Med Care2010;48:45e51.

61. Keating NL, Kouri E, He Y, Weeks JC, Winer EP. Racial differences in definitivecancer therapy in older women: are they explained by the hospital wherepatients undergo surgery? Med Care 2009;47:765e73.

62. Bickell NA, Aufses Jr AJ, Chassin MR. The quality of early-stage breast cancercare. Ann Surg 2000;232:220e4.

63. Hand R, Sener S, Imperato J, Chmiel JS, Sylvester JA, Fremgen A. Hospitalvariables associate with quality of care for breast cancer patients. JAMA1991;266:3429e34.

64. Hiotis K, Ye W, Sposto R, Goldberg J, Mukhi V, Skinner K. The importance oflocation in determining breast conservation rates. Am J Surg 2005;190:18e22.

65. Anderson B, Kaufman C, Kiel K, Carlson C. Colloquium: ensuring optimalinterdisciplinary breast care in the United States. American Society of BreastDisease. Available from: http://www.asbd.org/downloads/Colloquium/ASBD_Colloquium_Proceedings.pdf [accessed January 10, 2010].

66. Calman K, Hine D. A policy framework for commissioning cancer services. Areport by the expert advisory group on to the Chief Medical Officers of Englandand Wales; April 1995.

67. Tataru D, Robinson D, Moller H, Davies E. Trends in the treatment of breastcancer on Southeast England following the introduction of national guidelines.J Public Health (Oxf) 2006;28:215e7.

68. Haward RA. The Calman-Hine report: a personal retrospective on the UK’s firstcomprehensive policy on cancer services. Lancet Oncol 2006;794:336e46.

69. Rouse AM, Jooly K, Stevens AJ. Has Calman-Hine succeeded? Analysis of breastcancer procedure loads per consultant from before and after the Calman-Hinereport. Breast 2001;10:55e7. doi:10.1054/brst.2000.0210.

70. Haward R, Amir Z, Borrill C, et al. Breast cancer teams: the impact of consti-tution, new cancer workload, and methods of operations on their effectiveness.Br J Cancer 2003;89:15e22.

71. Brucker SY, Bamberg M, Jonat W, et al. Certification of breast centers inGermany: proof of concept for a prototypical example of quality assurance inmultidisciplinary cancer. BMC Cancer 2009;9:228.

72. Brucker SY, Schumacher C, Sohn C, Rezai M, Bamberg M, Wallwiener D,Steering Committee. Benchmarking the quality of breast cancer care ina nationwide voluntary system: the first five-year results (2003e2007) fromGermany as a proof of concept. BMC Cancer 2008;8:358.