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Introduction

These publications indicate that breast cancer management is highly specialised and imply that it is best done in major metropolitan centres where multidisciplinary expertise is available on-site. However, the need for specialised centres for breast cancer management is questionable. ⁶ Submissions from rural women to the Government inquiriesdescribed the increased burden imposed on them and their families in travelling for treatment and their consequent lack of treatment choices. ³ Many country people prefer local treatment and expect that their local hospital will provide the highest standard of care. However, to our knowledge there have been no publications on how breast cancer is managed in Australian rural centres. To provide this information, we conducted a three-year survey of breast cancer management in the practice of a general surgeon (B R T) in the rural Victorian town of Echuca.

Setting

Histology and cytology services are provided at Shepparton. A daily courier service transports specimens to the laboratory and reports are faxed within 48 hours. Hormone receptor studies on paraffin-embedded material with immunoperoxidase stains are available on request.

Patients

Between September 1992 and August 1995, there were 1992 new patients (excluding emergencies and in-hospital consultations); 275 (14%) were seen for breast conditions. All of these were referred directly by their general practitioners.

Surgery was offered for suspected malignancy and for a palpable breast lump that was either atypical on cytological examination, or was causing undue anxiety to the patient. Eighty-two patients (30% of those with a breast condition) had surgery; 57 had benign disease and 25 had cancer. Of those with cancer, 22 were diagnosed by fine-needle aspiration biopsy, 24 by mammography, and two by open biopsy (some patients had more than one form of test). Three patients with advanced breast cancer did not have surgery, giving a total of 28 with breast cancer (10% of the 275 with a breast condition). To our knowledge, none of the remaining 190 have since developed breast cancer. Nine of the 82 patients undergoing surgery had wire-localised excisions of lesions detected by mammography; four had carcinoma.

Surgical treatment

Clearance of axillary lymph nodes was undertaken for 15 of the 17 patients who had wide local excision of their primary breast cancers (for 12 this was done in Echuca and for three after they chose to go to Melbourne for further management). Two patients (aged 73 and 76, with tumours of 11 mm and 13 mm diameter, respectively) did not undergo axillary clearance, as it was considered that a positive lymph node yield would not alter their treatment regimen. They were given adjuvant tamoxifen alone.

Altogether, 17 axillary clearances were done in Echuca (12 in association with a wide local excision and five with a modified radical mastectomy). The mean lymph node yield for those operated on in Echuca was 13 nodes (range, 4-29). Yields from the three patients who had axillary clearances by breast specialist surgeons in Melbourne were six, eight and 12 nodes, respectively.

Specialist liaison

Other treatment

Adjuvant radiotherapy was given to only nine of the 17 patients who underwent breast-conserving surgery. Seven of the other eight had small primary tumours (up to 12 mm diameter); the decision to omit radiotherapy was made for five of these by the oncologists consulted at the time or, for two, by the patients themselves, who chose not to travel 200 km to Melbourne for treatment. Another patient had undergone chest-wall irradiation in the past and was advised against having more.

Twelve patients were referred for chemotherapy; one refused, despite exhaustive discussions with her general practitioner, surgeon and the regional oncologist, and 11 were seen by regional oncologists for planning of the chemotherapeutic regimen. At first, chemotherapy was given by the regional oncologists at Shepparton, but after 1993 it was given by the local oncology nurse (M E G) at Echuca under the supervision of the patient's general practitioner, with indirect supervision by the oncologist in charge. Two patients participated in national chemotherapy trials through the Bendigo Hospital Oncology Department; another patient was invited to participate but declined to do so.

Adjuvant hormonal therapy was widely used. All post-menopausal patients with oestrogen receptor-positive tumours were prescribed tamoxifen. The decision to use this in patients with oestrogen receptor-negative tumours was made in conjunction with the regional oncologists.

Complications

Cosmetic results of surgery were acceptable to the patients and surgeon using subjective criteria (e.g., neat scar, no patient complaints). Careful consideration was always given to placement of incisions, design of mastectomy flaps, and use of drainage. ⁷ Fine absorbable subcuticular closure was used routinely.

Long-term outcome

Discussion

The frequencies of breast complaints (14% of new consultations) and of breast cancer (10% of breast complaints) in our practice were comparable with those found in two general surgical outpatient clinics in the United Kingdom. ^8,9 However, the percentage of breast complaints that came to surgery in Echuca (30%) fell midway between the percentages found at Reading and Newbury in 1993 (16%) ⁸ and in London in 1982 (45%). ⁹ These differences could reflect changes in surgical policy with time, as well as differences in local criteria for biopsy. The ratio of benign to malignant lumps excised in Echuca was only 2:1, also midway between the figures for Reading and Newbury (1:1) ⁸ and for London (3:1), ⁹ probably for similar reasons.

Modes of presentation and distribution across clinical stages in our series were similar to those found in a study of 856 patients with breast cancer from the Victorian Cancer Registry in 1990. ¹⁰ This study found that multidisciplinary management and use of breast conserving surgery was more likely for surgeons who treated more than 20 cases a year. In the Echuca series, with fewer than 10 cases a year, multi- disciplinary involvement and breast conservation rates were higher still. These differences reflect the different eras from which these reports have been derived, as breast cancer management strategies changed rapidly in the early 1990s, and make comparision of management strategies difficult to interpret.

Are nine breast cancers a year enough for a centre to maintain competence in managing the disease? About 90 new patients with breast conditions (benign and malignant) were seen each year. Assuming each was seen two to four times in the year, there were 250-300 breast examinations per year, allowing expertise in examination to be maintained. Operative technique and complication rates were comparable to peer standards. ¹¹

Management of breast cancer locally has numerous advantages for the country patient, not least of which is convenience. In fact, the travel involved (200 km) led one patient to refuse radiotherapy. On the other hand, local management has few, if any, disadvantages. Surgery for breast cancer is straightforward; more important are the management decisions. While "best practice" may require a multidisciplinary approach, we showed that this can easily be obtained by consultation with city colleagues on a case-by-case basis. Adjuvant therapy and follow-up can usually also be provided locally, provided that communication is maintained with the relevant specialists. Thus, it is important for rural doctors and nurses to keep up to date with trends in breast cancer management, but equally important that city-based centres of excellence encourage rural colleagues to participate in patient care.

No patients in this series had their cancers detected by the regional mammographic screening program. Possibly, some patients from the Echuca region were identified in this way, but were referred to surgeons in Melbourne, as has occurred in other rural locations, leading to criticism. ¹² However, as the standard of care provided in rural hospitals becomes acknowledged and patients' wishes about treatment location are taken into account, definitive management at local centres should become a policy for screening programs.

Each of the potential inadequacies of isolated or small-volume practice (as identified in the House of Representatives Report on the management and treatment of breast cancer in Australia) ¹ is addressed at Echuca, as is likely at many other country centres. Although relatively few new breast cancers were detected and treated each year, most were managed in consultation with other specialists. Operative technique and complication rates were comparable to peer standards; cosmetic results were considered satisfactory; patients had access locally to literature about breast cancer and treatment options, supportive counselling, a prosthetics service and chemotherapy and were offered referral for breast reconstruction after mastectomy; and several patients participated in trials of chemotherapy regimens. However, quality assurance was difficult; while surgical morbidity was monitored by the surgeon, formal review of adjuvant therapies' morbidity was lacking and round-table case discussions and histopathological or radiological review sessions were difficult to organise. It remains the responsibility of individual rural practitioners to seek such interdisciplinary contact as part of their continuing medical education. We conclude that a multidisciplinary service of high standard can be provided to patients with breast disease irrespective of their rural location, provided that they are prepared to travel for adjuvant therapy and for second opinions, if warranted.

Acknowledgements

References

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