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Can "best practice" be achieved outside metropolitan centres?
MJA 1997; 166: 25
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©MJA1996
Treatment of breast cancer in Australia has been extensively
discussed recently, and a recent report 1 has emphasised the need for
multidisciplinary management in centres which are, of necessity, in
urban areas. However, a recent South Australian study showed that
almost 25% of breast cancers occur in women who live outside urban
areas, 2 and there are about
1.5 million women at risk of breast cancer in country areas
(calculated from Australian Bureau of Statistics data for women aged
over 30 years). BreastScreen Australia, which operates in every
State and Territory, plans to screen about a third of these (including
70% of women aged 50-69 years), so that many new, early breast cancers
will eventually be detected in rural women. Nevertheless, there is
little information about the treatment of breast cancer in rural
areas. Tulloh and Goldsworthy's study of breast cancer management in
a Victorian country town (in this issue of the Journal) provides valuable information for the debate on how best to deliver
treatment to women in rural areas.
There is abundant evidence that breast-conserving surgery achieves
disease control with good cosmesis in many breast cancer patients. No
studies have shown any difference in long term survival rates between
women who have had breast-conserving surgery and those who
have had a mastectomy for a similar type and stage of disease, and
breast-conserving surgery is widely accepted as the preferred
treatment for early-stage breast cancer. 3 However, there is substantial
geographic variation in the use of breast conservation as standard
treatment in both Australia and the United States, 4,5 and there is concern that time,
travel and communication may prove obstacles to such treatment in
rural areas. Tulloh and Goldsworthy show that this need not be so.
Experience at metropolitan centres in Australia shows that more than
50% of primary breast cancers are now treated conservatively;
Tulloh's index of 68% is higher.
This may be an issue for training of surgeons: those who have had
appropriate experience during their higher surgical training are
likely to retain competence, despite a relatively small workload.
Training in breast surgery has been greatly improved by the
development of specialist surgical breast units in metropolitan
teaching hospitals. In addition, the establishment of
reaccreditation and continuing education programs within the RACS
ensures that every surgeon who practises breast surgery has the
opportunity to be informed of new treatment developments. Although
the rate of surgical complications reported by Tulloh was higher than
would be expected for a specialist surgeon (those who treat more than
100 breast cancers a year would rarely see skin-flap necrosis after a
mastectomy and would expect a haemotoma rate of 2%-3% after open
biopsy), such rates are acceptable in a general surgical practice.
The benefits of multidisciplinary management of breast cancer have
been debated for some time. Multidisciplinary units in metropolitan
centres are justified by their logistic advantages, by the
opportunity to establish high standards with consistent peer review
and by the small, but demonstrable, improvement in outcome. 7,8 The National Health and Medical
Research Council clinical guidelines 9 espouse the principle of
multidisciplinary care, but also point out that this can be achieved
outside integrated treatment centres, by consultation between
appropriate specialists. Tulloh and Goldsworthy have demonstrated
that this can be done efficiently. Cost and logistics prevent the
establishment of rural radiation treatment centres, but many
medical and radiation oncologists visit regional centres for
consultations and treatment planning. Electronic communication
between rural and metropolitan centres can also facilitate
multidisciplinary management. In this context, the expertise of a
local specialist who understands the circumstances and needs of
patients living in remote areas is invaluable in planning treatment.
Australians who live in cities sometimes believe that those who live
in the country accept that access to some components of health care is
restricted. The determination of rural specialists and nurses like
Tulloh and Goldsworthy to demonstrate that high standards of care,
comparable to those in urban Australia, can be achieved in rural
centres is an example to all health professionals. In addition, their
demonstration that breast cancer can be managed effectively in rural
centres serves as a model for other cancers and shows that, with
effective communication, there is no insuperable barrier to high
standards of health care in rural Australia.
Colin M Furnival
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©MJA 1996
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© 1996 Medical Journal of Australia.
About five million Australians (almost 30% of the population) live
outside metropolitan centres, in regional towns or more remote
areas. Providing good health care for these people, spread over such a
large area, has always been a challenge. Recently, concern has
focused on access to general practitioner services in rural and
remote areas, but access to specialist care is equally important.
Surgeons in rural areas, unlike their metropolitan counterparts,
are responsible for a broad range of surgical care and do not have the
opportunity to concentrate exclusively on a narrow field of
practice, such as breast surgery. In recognition of this, the Royal
Australasian College of Surgeons (RACS) has established a Division
of Rural Surgery, which provides a forum for discussion of rural
surgical services and continuing medical education for surgeons who
live and work at a distance from major teaching institutions.
the expertise of a
local specialist who understands the circumstances and
needs of
patients living in remote areas is invaluable in planning treatment
Concern has also been expressed that limited experience in surgical
management of breast cancer may be an impediment to "best practice".
As recently as 1986, 25% of surgeons who treated breast cancer in
Victoria treated fewer than five cases a year. 6 While most urban surgeons now agree
that breast cancer should be treated in a multidisciplinary setting
by a specialist who treats many breast cancers, almost 50% of rural
surgeons believe this is not necessary (National Health and Medical
Research Council National Breast Cancer Centre and RACS Joint Study,
personal communication from Dr S Redman, Director, National Breast
Cancer Centre, Sydney, NSW).
Senior Visiting Specialist, Surgical Breast Unit
Royal Brisbane Hospital, QLD.