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Randomised controlled trial of effects of early discharge after surgery for breast cancer

BMJ 1998; 317 doi: https://doi.org/10.1136/bmj.317.7168.1275 (Published 07 November 1998) Cite this as: BMJ 1998;317:1275

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early discharge after surgery for breast cancer

Dear Sir

We read with interest Bundred et al's1 article on early discharge
after surgery for breast cancer. Whilst we are pleased that psychological
implications are being examined, we feel some important aspects of the
policy of earlier discharge have been inappropriately or inadequately
researched and warrant further investigation.

Firstly, there is a drawback with applying a randomised controlled
trial methodology in situations such as this, where patients are making
choices about their own care. This is a self-selecting process which
needs to be taken into account in research design. Without this, a
randomised controlled trial will study a biased sample, including some
patients who might not otherwise have considered earlier discharge but
more likely excluding those who are most committed to the idea and who 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 stressed the need to involve both cancer 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.

Secondly, we agree with Lesley Fallowfield's2 editorial comments that
the impact of early discharge upon a woman's carers must be examined in
more detail. As she stresses, the earlier discharge of patients who are
frail after surgery will simply transfer the burden of care. The practice
of speedier discharge might well appeal to patients but at the same time
place unreasonable demands on their carers.

Furthermore, whilst it may appear to be an efficiency
saving on hospital bed usage, the primary care back-up may
be left with increased demands but no additional resources.

We have recently carried out an audit of the psychological
implications of earlier discharge and found psychological adjustment,
levels of satisfaction and involvement in the decision regarding timing of
discharge to be high amongst both patients and carers.

Whilst this may offer important economic savings, our
findings support the view that early discharge following
surgery for breast cancer is not appropriate for all women.
Working to a formal protocol, we found that 27% of cases
were eligible for early discharge and in most cases this
proceeded successfully.

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

Yours faithfully

Diana Harcourt, Research Psychologist, The Breast Care Centre,
Frenchay Healthcare Trust, Bristol. BS16 1LE (0117)
9701212 ext 3492.

Simon Cawthorn, Consultant Surgeon, , The Breast Care Centre,
Frenchay Healthcare Trust, Bristol.

Nicholas Ambler, Clinical Psychologist, Frenchay Healthcare Trust,
Bristol.

Nichola Rumsey, Reader in Psychology, Department of Psychology,
University of the West of England, Bristol.

1Bundred, N., Maguire, P., Reynolds, J., Grimshaw, J., Morris, J.,
Thomson, L., Barr, L. & Baildam, A. (1998). Randomised controlled
trial
of the effects of early discharge after surgery for breast
cancer, BMJ, 317, p1275-1279.

2 Fallowfield, L. (1998). Early discharge after surgery for breast
cancer,
BMJ, 317, p 1264-1265.

----------------------------------------
Harcourt, Diana2
Email: Diana2.Harcourt@uwe.ac.uk

Competing interests: No competing interests

13 November 1998
Diana Harcourt