Overview:

Despite a two trillion dollar U.S. budget, we have limited information on outcomes of medical care. We do know that there is a great deal of variation in how medicine is practiced in various regions of the USA . We also know there are major variations in the cost of care. Because of a lack of information on the outcome or results of care, it is extremely difficult to compare the value of services provided by our medical system, i.e. the outcome of care as related to cost. If we could establish the value of specific medical services, both payers and consumers could make better health care choices.

We have had a long interest in attempting to measure quality of care and physicians' performance, in an attempt to get a handle on the process of measuring value.^1-2 We have recently re-organized our approach to care and joined with the Rad-Net organization. In the near future, we should be in a position to measure the costs of providing breast care. This should give us a head-start in measuring value. We anticipate making our results transparent to both payers and consumers as part of our anticipated goal of competing based on the value of our services.

Mortality:

The classic measures for outcome of breast cancer care are survival and recurrence rates. Survival is of course the most important, but in breast cancer care, initial survival tends to be so good that early mortality rates are of limited practical value. Most patients who die during the first one or two years of treatment die because of the aggressive biologic nature of their tumor. It is thus quite difficult to determine the influence of quality of care under these conditions.

Contrast the situation with breast care to the situation with cardiac surgery, in which 30-day mortality has a close correlation with quality of care. To accurately compare survival between various breast care centers or individual providers of care requires large numbers of patients and long-term follow up. For the most part, this information is not available.

Fortunately, with regard to the care offered at our center, we do have long-term survival data that has been independently collected and available for public review. I have had a 30+ year commitment at a single institution (St. Joseph Hospital in Orange, CA). During that time period, the hospital collected mortality data on all of my cancer patients. Our survival statistics were compared to that of the state of California and the nation. Table 1 summarizes the survival rates over a 5-year period (1999-2004) of breast cancer patients whom I have personally diagnosed and treated for breast cancer .The table clearly demonstrates that my patients have had better survival rates than those of the state and the nation.

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Table I: Breast cancer survival rates for a single surgeon (Dr. John West), as compared to the state and nation.

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Recurrence rates:

Another key measurement of outcome is rate of local recurrence. Local recurrence refers to the rate at which cancers of the breast recur locally after performing the initial definitive breast cancer surgery. This would include recurrences within the breast following the initial lumpectomy, with or without radiation therapy. It would also include chest wall recurrences, following mastectomy. We believe that with aggressive pre-surgical planning and meticulous surgical techniques, rates of recurrence could be minimized.

To evaluate our experience, we looked at all cases of ductal carcinoma in-situ (DCIS) which were treated with local excision for the time period spanning 1992-2002. We included only those patients who were followed for an excess of 5 years, and our mean time of follow-up was 8.2 years. The following is an abstract of published results.³

Background : Two DCIS treatment controversies are: What is the preferred margin width for patients undergoing lumpectomy plus radiation therapy, and is there a subgroup that can be safely treated with lumpectomy alone? A multidisciplinary team (MDT) was established to evaluate these issues.

Methods : Patients with DCIS who were candidates for breast-conservation were divided into two groups. Group I had a minimum 5mm margin and received radiation therapy, and Group II had a minimum 10mm margin and received no radiation therapy.

Results : 152 patients (153 cancers) met the inclusion criteria. The median follow-up was 8.2 years. Overall, there were 6 recurrences (3.92%); 1 of 71 recurred in Group I (1.40%), and 5 of 82 recurred in Group II (6.01%).

Conclusion : 5mm margins plus radiation results in low rates of recurrence. A subgroup of DCIS patients can be identified in which radiation can be safely avoided. The MDT approach to managing DCIS enhances the potential for improved outcomes.

Our results compare very favorably with results of previously published studies. In fact, in the sub-group of patients who were over 40 years of age who received lumpectomy and radiation therapy, there were no recurrences. Our single recurrence following lumpectomy and radiation was in a 37 year female who had extensive disease, but refused mastectomy. We believe that our low rates of local recurrence results from our long-term commitment to high-quality multidisciplinary care of our patients with DCIS.

Surrogate measures of outcome:

We believe that an important trend in breast cancer care will be a new focus on evaluating the outcome of care by various providers. Centers which can demonstrate improved outcomes will thrive in a competitive marketplace in which results of care are made transparent to the public, referring doctors, and the payers.

One of the greatest challenges in creating a value-based (outcome-to-cost ratio) competitive model is that we have limited knowledge of the specific factors which influence outcome. We have even less comparative data on the cost of care.

Two factors associated with improved outcomes in terms of the surgical aspects of breast cancer care have been documented. The first is surgical volume, and the second is specialty training.⁴ As is true for most aspects of complex surgical care, high volume is generally associated with favorable results. Thus, there is solid data which suggests that patients who are cared for in a busy specialty center, staffed with highly trained specialists, can anticipate better outcomes.

Since it is impractical to measure quality of care based on recurrence rates and mortality, there is currently a growing trend among providers to identify aspects of care which are associated with improved outcomes. One such aspect is having all newly diagnosed breast cancer patients presented to a multi-disciplinary treatment planning conference. Such measures, which are assumed to be associated with a favorable outcome, are referred to as “surrogate markers”.

Although many national organizations are attempting to identify surrogate markers that are linked to improved outcomes and can be easily measured, there is to date little consensus on which surrogate markers are appropriate. At present, there is insufficient data to show a correlation between any given marker of surgical care and outcome. There is concern among physicians that such markers will be selected by the government or payers, and these markers may burden physicians with added time and expense without improvements in outcomes.

Our approach to the issue of improving outcomes and controlling costs is unique in terms of breast care. We have developed an exciting new care model in which the breast surgeon, the breast imager, and the breast oncologist work as an organized team to treat the entire spectrum of breast health issues. Rather than analyzing a single aspect of breast care, we can evaluate the entire cycle of care from prevention and early detection, to treatment and recovery. This global perspective will enable us to focus on issues such as efficiency of care, cost-containment, and outcomes analysis. We anticipate making our results available to the public and to payers in an effort to stimulate competition among providers. Over time, this form of competition should lead to improved outcomes and help control costs.

This concept of value-based competition in the medical marketplace has been well defined in a recently published book by Michael Porter entitled: Redefining Health Care: Creating Value-Based Competition on Results. We believe that Michael Porter is a visionary, and that his concept of value-based competition is the best answer to the current health care crisis. Our breast care team is committed to applying Porter's principals to our organization.

Reference:

1.) West JG, Sutherland, M.L., Link, J.S., Margileth, D.A. A Breast Cancer Care Report Card. An Assessment of Performance and a Pursuit of Value. Western Journal of Medicine, April 1997; 166(4):248-252.

2.) West JG., Sutherland, M.D., Hays, P.A., West, J.E., Margileth, J. Measuring Physicians' Performances and Marketing the Results: A Breast Cancer Model. The Breast Journal Volume, 1998; 5(2):141-147.

3.) West JG, Azhar Q, Liao SY, Sutherland ML, Chen J, Chacon M, Fanning C. Multidisciplinary management of Ductal Carcinoma in Situ: a 10 year experience. Am. J Surg. 2007;194:532-4

4.) Houssami N, Sainsbury R. Breast cancer: Multidisciplinary care and clinical outcomes. European J Cancer, 2006;42:2480-91.