Early discharge after surgery for breast cancer

EDITOR—We are pleased that psychological implications of early discharge after surgery for breast cancer are being examined1 but think that some important aspects of the policy have been inappropriately or inadequately researched and warrant further investigation.

There is a drawback to applying randomised controlled trial methodology in situations such as this, where patients are making choices about their care. A self selecting process operates and must be taken into account in the research design; if it is not, a randomised controlled trial will study a biased sample—it will include some patients who might not otherwise have considered earlier discharge and exclude those who are most committed to the idea and do not want to risk being randomised to the control condition. This is not a peripheral issue. The policy framework for commissioning cancer services has emphasised the need to involve both patients and their carers in decisions about their treatment. This involvement should extend to the decision regarding the timing of the patient's discharge from hospital.

We agree with Fallowfield that the impact of early discharge on a woman's carers must be examined in more detail.2 As she emphasises, the earlier discharge of patients who are frail after surgery will simply transfer the burden of care. Earlier discharge might well appeal to patients but might place unreasonable demands on their carers. Furthermore, while early discharge from hospital may be an efficiency saving on hospital bed use, primary care may be left with increased demands to provide back up but no additional resources.

We recently audited the psychological implications of earlier discharge and found that psychological adjustment, levels of satisfaction, and involvement in the decision regarding timing of discharge were high among both patients and carers. Early discharge after surgery for breast cancer may offer important economic savings, but our findings support the view that it is not appropriate for all women. Working to a formal protocol, we found that just over a quarter of patients were eligible for early discharge, and in most cases this proceeded successfully.

The wider implications of this practice still need to be considered further.