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Treatment variation in early breast cancer in the UK

BMJ 2020; 371 doi: (Published 01 December 2020) Cite this as: BMJ 2020;371:m4237
  1. David Dodwell, senior clinical research fellow1,
  2. Yasmin Jauhari, clinical research fellow2,
  3. Toral Gathani, senior clinical research fellow3 4,
  4. David Cromwell, professor5 ,
  5. Melissa Gannon, research fellow5,
  6. Karen Clements, project manager6 ,
  7. Kieran Horgan, consultant breast surgeon7
  1. 1Nuffield Department of Population Health, University of Oxford, Oxford, UK
  2. 2Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
  3. 3Cancer Epidemiology Unit, Nuffield Department of Population Health, University of Oxford
  4. 4Department of Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
  5. 5Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, UK
  6. 6Public Health England, Birmingham UK
  7. 7Department of Breast Surgery, St James’s University Hospital, Leeds, UK
  1. Correspondence to: D Dodwell david.dodwell{at}

David Dodwell and colleagues examine why treatment variation continues to occur in breast cancer despite high quality evidence on best practice

One in seven women will develop breast cancer. Although the number of people diagnosed with this common disease is increasing, mortality continues to fall. In the UK, almost 80% of women diagnosed with breast cancer are alive 10 years after their initial diagnosis.1 The survival gains seen over recent decades have largely been achieved through earlier diagnosis and more effective treatments. Nonetheless, there is still room for improvement. Population based mortality for breast cancer among those aged <75 years in the UK ranges from 13 to 32 per 100 000,2 and UK survival rates from breast cancer are still reported to be below those in countries such as the United States and Australia.3

The treatment of breast cancer is multimodal, comprising local treatment (surgery and radiotherapy) and systemic treatments (endocrine therapy, chemotherapy, and biological therapy). Breast conserving surgery is, in most cases preferred to mastectomy (removal of all the breast tissue) providing equivalent oncological outcomes, but with quality of life benefits. The choice of systemic therapies is driven by risk of recurrence, determined by stage, grade, and molecular pathological characteristics. For example, patients with ER (oestrogen receptor) positive cancer are treated with endocrine therapy and those with HER2 (human epidermal growth factor receptor 2) positive disease commonly receive trastuzumab and chemotherapy. Although randomised controlled trials have provided good evidence for optimal treatment, variation still occurs in the UK and may be one factor in reported lower survival rates.

Treatment variation

Surgery is the most important treatment for early breast cancer. The 2018 National Institute for Health and Care Excellence (NICE) guidelines maintain that patients should be treated “irrespective of age, with surgery and appropriate systemic therapy, rather than …

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