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A particular advance was the results of randomised clinical trials in the mid 1980s³ which definitively showed that breast-conserving surgery followed by breast irradiation produced much better cosmetic results than mastectomy, without compromising rates of metastasis or survival. Breast-conserving surgery is now an accepted part of "best practice" treatment for most women with early breast cancer, and the National Health and Medical Research Council (NHMRC) has produced guidelines⁴ on its use (see Box).

In this issue of the Journal, Craft and colleagues provide national data on patterns of breast cancer surgery. Their survey of Medicare data for 1993 found that breast-conserving surgery was undertaken in 39.9% of women reimbursed for breast cancer surgery, but that frequency varied significantly between rural and urban women (33.9% versus 41.9%) and between States (from 33.8% in Western Australia to 49.2% in South Australia/Northern Territory). Similar variations in frequency of breast-conserving surgery have been seen in the United States.^6,7

How can we account for these differences? Craft and colleagues suggest that accessibility of radiotherapy services, which are generally located in or near capital cities, may affect a patient's decision to have breast-conserving surgery, although the Victorian survey suggested this is important in only 8% of cases.⁵ Furthermore, the rate of breast-conserving surgery in a particular rural Victorian practice between 1992 and 1995 was found to be 68%.⁸ These results suggest that the individual surgeon's attitude still plays an important part in the decision.

In drawing conclusions from this study, its limitations must be considered. Craft and colleagues claim to have identified about 60% of the predicted number of women with breast cancer treated in 1993, but these included only patients treated on a fee-for-service basis and therefore excluded all non-insured patients treated in public hospitals. A consistent difference between public and private patients would limit the significance of the results.

The study also found that frequency of breast-conserving surgery decreased significantly with patient age. However, this result may not be accurate as the study selection criteria excluded lumpectomy if it was not accompanied by axillary dissection or radiotherapy. It is suspected that radiotherapy is more likely to be omitted -- often inappropriately -- after breast-conserving surgery in older women, many of whom receive follow-up treatment with tamoxifen alone. Unfortunately, the study provides no information on this.

Despite these limitations, the rates of breast-conserving surgery reported by Craft and colleagues are low in comparison with estimates that about 70% of mammographically detected cancers and 50% of clinically detected tumours are suitable for breast conservation.⁴ For example, rates exceeding 50% are routinely reported in metropolitan centres and higher rates have been reported by individuals (e.g., Tulloh and Goldsworthy⁸).

However, other measures may be needed. The Royal Australasian College of Surgeons (RACS) has recognised the need for ongoing training and continuing education and reaccreditation programs for surgeons.

For rural women, a regional multidisciplinary team approach is encouraged, as exemplified in the report of breast cancer management in a Victorian country town, where formal links existed with the oncology unit at a Melbourne hospital.⁸

It is not yet known how far the strategies already in place have overcome problems such as those identified by Craft and colleagues and satisfied the House of Representatives' goal that "the Australian woman who is faced with dealing with breast cancer, regardless of where she lives and whatever her social and economical background, should have the very best treatment and support available".¹⁰

As accurate figures on the pattern of surgical care of women with breast cancer become available, better planning and distribution of resources for educating physicians and surgeons about breast cancer may be possible. This would provide women with a greater variety of treatment options and more involvement in decision-making about their care. If necessary, specific educational programs may also be directed at minority patient groups, such as those of a non-English-speaking background, and subgroups, such as rural patients, elderly patients and the disadvantaged.

Best practice in the surgical management of breast cancer has come a long way in the past 20 years, and with increased patient involvement in management decisions and a well-educated multidisciplinary team new treatment advances will rapidly find their way into day-to-day clinical practice.

John P Collins
Head, Breast Unit, Royal Women's Hospital; and Surgeon, Royal Melbourne Hospital,Melbourne, VIC.

1. Commonwealth Department of Human Services and Health. Better health outcomes for Australians. Canberra: The Department, 1994.
2. Taylor R, Smith D, Hoger A, et al. Breast cancer in NSW. Sydney: Cancer Epidemiology Research Unit, NSW Cancer Council, 1994.
3. Fisher B, Bauer M, Margolese R, et al. Five-year results of a randomized clinical trial comparing total mastectomy and segmental mastectomy with or without radiation in the treatment of breast cancer. N Engl J Med 1985; 312: 665-673.
4. National Health and Medical Research Council. Clinical practice guidelines: the management of early breast cancer. Canberra: NHMRC/AGPS, 1995.
5. Hill DJ, White VM, Giles GG, et al. Changes in the investigation and management of primary operable breast cancer in Victoria. Med J Aust 1994; 161: 110-122.
6. Farrow DC, Hunt WC, Samet JM. Geographic variation in the treatment of localised breast cancer. N Engl J Med 1992; 326: 1097-1101.
7. Nattinger AB, Hoffmann RG, Shapiro R, et al. The effect of legislative requirements on the use of breast-conserving surgery. N Engl J Med 1996; 335: 1035-1040.
8. Tulloh BR, Goldsworthy ME. Breast cancer management: a rural perspective. Med J Aust 1997: 166; 26-29.
9. Breast cancer consensus report. Med J Aust 1994; 161 Suppl 7: S1-S16.
10. House of Representatives Standing Committee on Community Affairs. Report on the management and treatment of breast cancer in Australia. Canberra: AGPS, 1995.
11. Sainsbury R, Howard B, Rider L, et al. Influence of clinician workload and patterns of treatment on surviving from breast cancer. Lancet 1995; 345: 1265-1270.