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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

Rapid Response:

Observational bias

Dear Editor,

Bundred et al showed that there were no increased rates of physical
or psychological illness resulting from early discharge after surgery for
breast cancer (1). However the end point measurements of shoulder movement
were subjected to potential bias as they were assessed by the
investigators and not independent observers. In addition seroma formation,
wound infection and arm or hand swelling were not measured objectively
resulting in further bias.

Five out of forty nine patients (10%) were unable to be discharged at
two days after surgery despite being randomised into the early discharge
group because of medical problems or home circumstances. As the trial was
conducted to determine whether early discharge increased the rates of
physical or psychological illness, these patients should have been
excluded from statistical analysis. In addition 42 patients in the early
discharge group had an axillary drain in situ three days postoperatively -
suggesting that seven patients were in fact discharged without their
drains. The trial design specifically stated that the test group included
only those discharged at 2 days ‘with an axillary drain still in place’.
It is therefore misleading to include those without drains on discharge in
the analysis.

It is interesting to note that 77% of patients allocated to standard
discharge were very pleased with the care given by the breast care nurse
compared with 90% of those allocated to early discharge. One might
speculate that more attention was being paid to the latter group than to
the former.

1) Bundred N, Maguire P, Reynolds J et al. Randomised controlled
trial of effects of early discharge after surgery for breast cancer. BMJ
1998;317:1275-9.

Yours faithfully,

Andy Huang
Specialist Registrar in General Surgery

K Ravi
Specialist Registrar in General Surgery

Robin Souter
Consultant in Breast Surgery

Department of Surgery,
Milton Keynes Hospital,
Standing Way,
Eaglestone,
Milton Keynes MK6 5LD.
Phone:01908-660033
Fax: 0171-486-0883
email:101652.1757@compuserve.com

Competing interests: No competing interests

16 November 1998
Andy Huang
Specialist Registrar In General Surgery
Milton Keynes General Hospital