More centralisation of services is not needed

BMJ 1996; 312 doi: http://dx.doi.org/10.1136/bmj.312.7039.1156 (Published 04 May 1996) Cite this as: BMJ 1996;312:1156
  1. Bruce Sizer,
  2. Stephen Karp
  1. Consultant clinical oncologist Department of Clinical Oncology, Essex County Hospital, Colchester CO3 3NB
  2. Director COIN Project, North Middlesex Hospital, London N18 1QX

    EDITOR,—Charles R Gillis and David J Hole may have found evidence that survival of patients with breast cancer is improved if they are treated by specialist breast surgeons, but there is little scientific evidence that surgery influences survival from breast cancer to any significant extent and they collected no information on the details of treatment received.1 There is considerable evidence, however, to support the survival benefit of adjuvant hormone therapy and chemotherapy2 and of long term benefit from adjuvant radiotherapy.3 Correlation does not prove causation. If encouraging surgeons to work more closely with oncologists can achieve better access to adjuvant treatment and produce improved survival, this would be a much cheaper solution than to create large numbers of specialist breast units. The latter solution should be subjected to a full health technology assessment before being widely adopted.

    The gain in treatment benefit of referral to so called specialists over and above the application of clearly defined protocols is unclear. There is evidence of the slow adoption of novel therapies into clinical practice, both within4 and outside oncology. The faculty of clinical oncology of the Royal College of Radiologists is trying to address the problem of medical practice variation through the clinical oncology information network (COIN) project, a major strand of which is national comparative audit in oncology against professionally agreed guidelines of best practice.5

    While Gillis and Hole are correct in asserting “that there is a need to improve equity in the treatment of breast cancer” we do not need more centralisation of services leading to less equity; we do need timely protocols and guidelines widely and rapidly disseminated by using modern information technology. Recommendations from the Royal College of Radiologists on cancer management will soon be appearing on the worldwide web, and there can be no doubt that in future many cancer specialists will be using computer based information services to bring a high level of care to cancer patients irrespective of where they live


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