Editorials

Early discharge after surgery for breast cancer

Might not be applicable to most patients

Papers p   1275

With throughput and cost containment uppermost in purchasers' minds, any evidence that the length of hospital stays after surgery can be reduced without increasing physical or psychological morbidity must be music to their ears. The report by Bundred et al (p 1275)¹ complements that originally published by Boman et al from Sweden² and Bonnema et al from the Netherlands³ suggesting that early discharge after surgery for breast cancer is both safe and beneficial. However, before early discharge policies for women with breast cancer are widely implemented, several issues need further comment and a more thorough assessment.

Boman et al looked at physical outcomes and satisfaction in women who opted for either early discharge with a drain in situ two days postoperatively or routine discharge after drain removal. Both Bonnema and Bundred report data from randomised controlled trials comparing standard discharge with that of early discharge with a drain in situ. Bonnema et al found that early discharge at four days reduced the duration of drainage, the number of wound infections, and the need for seroma aspiration. Furthermore, patients' reported satisfaction was high, with no major differences in psychological morbidity. The early discharge group also seem to have benefited from increased social interaction and support from the family. Bundred et al examined effects of an even briefer hospital stay of two days compared with the standard 5-10 days. They too report no increase in physical or psychological morbidity. They also found that early discharge seemed to produce the additional benefits of less wound pain and greater shoulder mobility.

Such results are potentially very important as hospitalisation is not only expensive but also stressful.⁴ Surgical patients in general show higher levels of stress than medical patients, induced no doubt by psychological factors such as separation from the family but also fear of the physical procedures involved. Why therefore should we not be encouraging the widespread implementation of early discharge policies for women with breast cancer?

Breast cancer is still predominantly a disease of elderly women, many of whom may not have partners alive and well or other family members able to help in their nursing care and rehabilitation. An early discharge policy also depends on high input from specialist or community nurses, and many patients live in areas too remote to make visits from nurses possible. In Bundred et al's study almost two thirds (229/365) of women undergoing breast cancer surgery during the study period were ineligible for randomisation owing to their age, lack of home support, and travel difficulties for the specialist nurse. A further 36 (27%) eligible patients refused to join the trial, although reasons for this are not provided. In Sweden only 24% of women accepted the opportunity of early discharge with a drain in place.¹ These figures suggest that an early discharge policy would be either unsuitable or unacceptable to most women with breast cancer.

Other important questions concern the real and hidden costs of early discharge. Although Bundred et al's study will eventually include an economic analysis, none of these crucial data are available yet. The actual costs of community and specialist nursing are not insubstantial; and what of the burden on a woman's informal carers, who may have to take time off work to nurse their relative or friend? Changes in the delivery of cancer services, as well as cost containment issues, mean that after care and terminal care involving increasingly complex physical treatments have now become part of the families' responsibility. Although many families have more than adequate financial, physical, and mental resources to do this, for others it is an onerous burden, so the attitudes of carers and the stresses placed on them must be measured much more fully.⁵

Because some women will never be suitable for early discharge, it would be good to see an extension of one of the really interesting aspects of Bundred's paperthat of improved shoulder mobility in the early discharge group. This finding suggests that women in their home environment are probably having to do a great deal more for themselves (and their partners) than those languishing in a hospital bed. Perhaps we should be looking at more intensive physiotherapy to encourage arm movement for inpatients who cannot be discharged early.

Lesley Fallowfield, Professor. 

CRC Psychosocial Oncology Group, Department of Oncology, University College London, London W1P 7PL (l.fallowfield{at}ucl.ac.uk)

1. Bundred N, Maguire P, Reynolds J, Grimshaw J, Morris J, Thomson L, et al. Randomised controlled trial effects of early discharge after surgery for breast cancer. BMJ 1998; 317: 1275-1279[Abstract/Free Full Text].
2. Boman L, Bjorvell H, Cedermark B, Theve N, Wilking N. Effects of early discharge from hospital after surgery for primary breast cancer. Eur J Surg 1993; 159: 67-73[Medline].
3. Bonnema J, van Wersch A, van Geel A, Pruyn J, Schmitz P, Paul M, et al. Medical and psychosocial effects of early discharge after surgery for breast cancer: randomised trial. BMJ 1998; 316: 1267-1270[Abstract/Free Full Text].
4. Johnston M. Hospitalisation in adults. In: Baum A, Newman S, Weinman J, West R, McManus C, eds. Cambridge handbook of psychology, health and medicine. Cambridge: CUP, 1997:121-123.
5. Fallowfield LJ. Helping the relatives of patients with cancer. Eur J Cancer 1995; 31: 1731-1732.