Breast cancer in rural Australia

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
Senior Visiting Specialist, Surgical Breast Unit
Royal Brisbane Hospital, QLD.

1. House of Representatives Standing Committee on Community Affairs. Report on the management and treatment of breast cancer in Australia. Canberra: AGPS, 1995.
2. South Australian Cancer Registry. Epidemiology of cancer in South Australia. Adelaide: The Cancer Registry, 1996: 211-236.
3. Harries SA, Lawrence RN, et al. A survey of the management of breast cancer in England and Wales. Ann R Coll Surg Engl 1996; 78: 197-202.
4. Byrne MJ, Jamrozik K, Parsons RW, et al. Breast cancer in Western Australia in 1989. II. Diagnosis and primary management. Aust N Z J Surg 1993; 63: 624-629.
5. Farrow DC, Hunt WC, Samet JM. Geographic variation in the treatment of localised breast cancer. N Engl J Med 1992; 326: 1097-1101.
6. Hill DJ, Giles GG, Russel IS, et al. Management of primary, operable breast cancer in Victoria. Med J Aust 1990; 152: 67-72.
7. Sainsbury R, Haward B, Rider L, et al. Influence of clinician workload and patterns of treatment on surviving from breast cancer. Lancet 1995; 345: 1265-1270.
8. Gillis CR, Hole DJ. Survival outcome of care by specialist surgeons in breast cancer: a study of 3786 patients in the west of Scotland. BMJ 1996; 312: 145-148.
9. National Health and Medical Research Council. The management of early breast cancer. Clinical practice guidelines. Canberra: NHMRC/AGPS, Oct 1995.