ReviewBenefits from specialised cancer care
Section snippets
Is there a problem with existing services?
The literature on the efficacy of cancer services is extensive but still inconclusive.5 Cancer-registry data and hospital statistics show large variations in the frequency with which individual treatments are used and in the caseload for particular cancers among doctors treating cancer. Although these data are evidence of the fragmentation of current care-and they are mirrored by considerable differences in survival between different communities and populations, it is not proof that current
European comparisons
The large EUROCARE study was the most careful attempt yet to ensure “like with like” comparison and good quality assurance of the data, using cancer registries within countries rather than aggregated national data of uncertain quality. The 30 population-based registries had 800 000 patients with cancer diagnosed in 1978–85.6 Relative survival corrected for age was reported for 25 cancer sites. The survival of patients in the UK was lower than that for most other European countries, for 18 of
Non-surgical oncology in UK
Access to specialised care in the UK is not uniform. Clinical teams expert in a narrow range of cancers do exist but are not available everywhere. The UK has fewer cancer specialists per 100 000 population than other European countries.7, 8 A survey of the non-surgical management of early breast cancer carried out for the Royal College of Radiologists,9 revealed that the number of breast-cancer patients seen by clinical oncologists varied widely but 83% saw more than two new patients per week.
Nature of specialisation
There are many elements within specialist care-including training and skills, the composition of the multidisciplinary team, the volume of work undertaken by a unit or individual, and the provision of care within teaching or non-teaching hospitals or large regional or local hospitals. Studies that have tried to assess care have usually considered only one of these aspects of specialisation and have used different endpoints, such as perioperative mortality, surgical complication rates, or
Paediatric cancers
Cancer in childhood is rare but about 60% of children can now be cured by complex and intensive treatments. As treatments improved in the 1960s and 1970s, there was a movement towards the centralisation of the management of children with cancer. During the 1980s an association was shown between treatment in specialist childrens' cancer centres and improvements in survival in the UK and in North America.11
For childhood leukaemia, treatment within nationwide clinical trials was found to be
Testicular cancer
There is good evidence of a survival advantage for patients treated for testicular cancer in specialist centres.13, 14 Improved survival was associated with high caseload and with adherence to protocol-defined treatment doses. Specialist units made more use of intensive treatments and surgery and arranged the most appropriate staging investigations and follow-up than other units. Initial management by a urologist appears to be preferable to management by a general surgeon.15
At least one
Ovarian cancer
A group from Glasgow, UK, have shown significantly improved survival from the management of ovarian cancer in teaching hospitals, and they and others have shown that treatment by a gynaecologist yields better results than treatment by a general surgeon.18, 19, 20 These studies are unusual in that they addressed the value of multidisciplinary teams, and showed that multi-disciplinary therapy yields benefits that exceed those from any specialist working alone.
The Glasgow group have analysed the
Common cancers in adults
Lung cancer resection is done mainly by thoracic surgeons and a proposal that this procedure be carried out by general surgeons would be unlikely to gain support. Similarly, among physicians, a specialist is more likely than a non-specialist to make a diagnosis including histology (P L Rider, personal communication). Prompt referral for surgical assessment, the basis for the selection of appropriate cases for surgical management, depends on the referring physician. Since full diagnosis is a
Can specialised hospital cancer care be delivered by a network of services rather than exclusively by tertiary centres?
Few investigators have assessed whether it is possible to deliver high-quality care, equivalent to that obtained in specialised centres, by a network of units in general hospitals. Few opportunities to make such comparisons exist.
Three, very different, studies support the proposal that a network of specialised services in district general hospitals and in cancer centres can achieve good outcomes. The Manchester study of colorectal cancer49 suggests that specialist surgeons in district hospitals
Conclusions
Outcomes for many cancers vary widely, and there is much evidence to support the case for specialised care in its various forms. Stiller5 has noted that no study has ever shown a disadvantage from management in a specialised centre for any cancer. However, several studies have shown that there is no benefit from specialised care and that the results vary between cancers. Evidence for better long-term outcomes from specialised care is strongest for breast, ovarian, haematological, and rare
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