Sainsbury R, Haward B, Rider L, Johnston C, Round C
Department of Surgery, Royal Infirmary, Huddersfield, UK.
Lancet. 1995 May 20;345(8960):1265-70. doi: 10.1016/s0140-6736(95)90924-9.
Chemotherapy and hormone therapy prolong disease-free and overall survival for patients with breast cancer in the clinical-trial setting, but it is not clear if this translates into a benefit on a population basis. It is also not clear if surgical caseload has any influence on survival. We used cancer-registry data from 12,861 patients with breast cancer treated in Yorkshire, UK, between 1979 and 1988, and found that patients of surgeons with higher rates of usage of chemotherapy and hormone therapy (regional mean usage 9.3%, range 0-46%) had prolonged survival. There was considerable variation in survival of breast cancer patients between surgeons, but their rate of use of chemotherapy and hormone therapy explained about 26% of this survival variation. Had the practice of the surgeons with the better outcomes been used by all treating clinicians, 5-year survival would have increased by about 4-5%. Examination of differences in survival as a function of consultant caseload demonstrated poorer results amongst those surgeons treating less than 30 new cases of breast cancer per year (risk ratio [95% CI] for treating > 30 compared with < 10 = 0.85 [0.77-0.93]). We recommend that patients with breast cancer be dealt with only by clinicians who see more than 30 new cases per year and who have a full range of treatment options available within a multidisciplinary setting.
在临床试验中，化疗和激素疗法可延长乳腺癌患者的无病生存期和总生存期，但尚不清楚在总体人群中这是否能转化为实际益处。手术病例数是否对生存率有影响也不明确。我们使用了1979年至1988年间在英国约克郡接受治疗的12861例乳腺癌患者的癌症登记数据，发现化疗和激素疗法使用率较高的外科医生（区域平均使用率9.3%，范围0 - 46%）所治疗的患者生存期延长。不同外科医生治疗的乳腺癌患者生存率存在显著差异，但其化疗和激素疗法的使用率解释了约26%的生存率差异。如果所有治疗医生都采用治疗效果较好的外科医生的治疗方法，5年生存率将提高约4 - 5%。根据顾问医生的病例数对生存率差异进行分析，结果显示每年治疗新乳腺癌病例少于30例的外科医生治疗效果较差（每年治疗> 30例与< 10例相比的风险比[95%可信区间] = 0.85 [0.77 - 0.93]）。我们建议，乳腺癌患者应仅由每年诊治超过30例新病例且在多学科环境中有全套治疗方案的临床医生进行治疗。
