This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Skinner, K. A. Articles by Sposto, R. Search for Related Content PubMed PubMed Citation Articles by Skinner, K. A. Articles by Sposto, R. Related Collections Surgery

Breast Cancer: Do Specialists Make a Difference?

From the Departments of Surgery (KAS, JTH) and Preventive Medicine (DD, WY, RS), Norris Comprehensive Cancer Center, University of Southern California/Keck School of Medicine, Los Angeles, California.

Correspondence: Address correspondence and reprint requests to: Kristin A. Skinner, MD, NYU School of Medicine, Department of Surgery, 550 First Avenue, HCC 6H, New York, NY 10016-6481; Fax: 212-263-5045; E-mail: kristin.skinner{at}med.nyu.edu

	ABSTRACT

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION REFERENCES

 
Background: Many believe that breast cancer should be treated by specialists. We studied the effect of surgeon and hospital specialization on survival after breast cancer treatment in a large, well-defined patient population.

Methods: The Cancer Surveillance Program database for Los Angeles County was reviewed. Between 1990 and 1998, 43,411 cases of breast cancer were diagnosed, of which 29,666 had complete data on surgeon, hospital, and staging information. Patients were stratified on the basis of surgeon and hospital specialization, as well as by age, race, stage, surgical procedure, and surgeon and hospital case volume. An analysis of survival and its dependence on these factors was performed.

Results: Age, race, socioeconomic status, tumor size, nodal status, extent of disease, surgeon specialization, surgeon case volume, and hospital case volume were all associated with 5-year survival after diagnosis of breast cancer. Treatment at a specialty center did not affect survival. Multivariate analysis indicated that type of surgeon was an independent predictor of survival (relative risk, .77), as were both hospital and surgeon case volume.

Conclusions: Treatment by a surgical oncologist resulted in a 33% reduction in the risk of death at 5 years. The effect of surgical specialization cannot be entirely attributed to volume effects.

Key Words: Breast cancer • Specialists • Hospital volume • Surgeon case volume • Hospital volume • 5-Year survival

	INTRODUCTION

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION REFERENCES

 
A large body of literature is accumulating that evaluates the effect of hospital case volume on outcome after treatment for a variety of malignancies that require treatment with technically challenging operative procedures, such as liver resection, pancreaticoduodenectomy, pneumonectomy, sphincter-preserving surgery or pelvic exenteration for rectal cancer, esophagectomy, gastrectomy, radical prostatectomy, radical cystectomy, and radical nephrectomy.^1–19 Because of the complexity of these surgeries, perioperative (in-hospital or 30-day) mortality is significant and is the end point most often evaluated in these outcomes studies. Few studies include long-term survival as an end point. It is interesting to note that it is hospital case volume, rather than surgeon case volume, that affects outcome in these most challenging of surgical patients. This is believed to be due to the need for highly trained multidisciplinary teams to adequately manage these patients after surgery.¹⁹

Few data exist regarding the outcome after surgery for the more common cancers, such as colon cancer and breast cancer, which are less technically challenging and require little in the way of specialized care in the immediate postoperative period. For these patients, perioperative mortality is negligible, and the only significant end points are long-term survival and functional results. A single study has evaluated the effect of hospital case volume on the 5-year survival after surgery for breast cancer, and it demonstrated a 37.5% reduction in the risk of death for patients treated in hospitals performing >150 breast cancer surgeries per year compared with those performing 10 cases per year.²⁰ Although the effect of surgeon case volume and specialization has not been seen in the more complex procedures, in which exemplary intensive care and multidisciplinary management of common complications can mask any effect of surgical expertise, in the "easier" cases, adequate and appropriate surgery may well be the difference between long-term survival and recurrence. We hypothesized that treatment by a specialist in surgical oncology (SO) would lead to improved long-term survival in patients with breast cancer. Possible reasons for such improved outcome include a volume effect, improved surgical techniques, or more appropriate use of a multidisciplinary approach to the cancer patient. We reviewed a large, well-defined, population-based tumor registry to assess the effect of these factors on the outcome after treatment for breast cancer.

	METHODS

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION REFERENCES

 
Database and Patients
The Cancer Surveillance Program (CSP) database for Los Angeles County is a population-based program that reports to the Surveillance, Epidemiology, and End-Results Cancer Registry. Data retrieved from the database included patient age at diagnosis, race, socioeconomic status (SES), treating physician’s unique physician identification number (UPIN), diagnosis date, surgery date, admission date, date of last follow-up, type of surgery (breast-conserving or mastectomy), vital status, tumor size, extent of disease (local, regional, or distant), nodal status (uninvolved, regional, or distant), and treating hospital code. Each patient was assigned into one of the five SES categories—high, above average, average, below average, or low—by using census tract-specific population census data on median household income and average level of educational attainment for adults aged 25 years who resided in each census tract at the time of the 1970 census, the 1980 census, and the 1990 census.²⁰ Data were considered complete if patient age, dates of surgery and diagnosis, surgeon and treating hospital codes, tumor size, extent of disease, and nodal status were available. The patients included in this study were the female invasive breast cancer patients diagnosed from 1990 through 1998 in the CSP database. Ductal carcinoma-in-situ was not included. The CSP contains information regarding the treating hospital and physician. Only cases in which the treating hospital was identified were included in this study. The surgeon who was recorded on the admission date that was closest to the surgery date was assumed to be the one who performed the surgery for the primary cancer. Of 43,411 female invasive breast cancer patients in the database, 2,521 did not receive surgery, 1,889 were treated at hospitals outside of Los Angeles County, 926 had no treating hospital identified, and 8,409 had incomplete information on surgeon, hospital, and stage. The remaining 29,666 patients were the subject of this analysis. Figure 1 shows the included and excluded patients. The distribution of prognostic factors and survival of the patients who were excluded from the analysis, compared with those of the patients who were included, are listed in Table 1.

View larger version (31K): [in this window] [in a new window]   FIG. 1. Distribution of included and excluded patients. Excluded patients are in the boxes to the right. The final patient population included in the analyses is in the bottom left box.

The criteria for admission to the SSO are rather stringent and include that a surgeon be certified by the American Board of Surgeons; have completed either 1 year of SO specialty training or 3 years of practice in SO; have published at least three peer-reviewed articles pertaining to cancer; display evidence of an ongoing commitment to oncology through teaching, research, or involvement with local or national cancer organizations or activities; and maintain an active practice focused on oncology, with at least 50 major oncology cases in the last year. Members were identified through the SSO membership directories through 1998 and were assigned their UPIN numbers to maintain anonymity and confidentiality. UPIN numbers were obtained from the state licensing board. A total of 1,800 surgeons, 36 of whom were members of the SSO (2%), treated the 29,666 patients with breast cancer.

Definition of a Specialty Center
Cancer centers that are recognized by the National Cancer Institute as National Cancer Institute-designated cancer centers were considered specialty centers (SC; n = 6). All other hospitals (n = 121) were considered non-specialty centers (NSCs). Most patients were treated at NSCs (95.2%) rather than at SCs (4.8%).

Statistical Analysis
The outcome measure used was time to death from any cause, calculated from the date of diagnosis of primary breast cancer. Follow-up through the end of 1998 was available. Plots and estimates of survival probabilities were computed by using the product-limit estimate. Standard errors for survival probabilities were calculated with the Greenwood formula.²² Surgeon volume effects were assessed by dividing the surgeons into groups based on the average number of breast cancer surgeries performed per year, as represented in the CSP database. Years in which the surgeon performed no surgeries were excluded from the average to correct for surgeons moving from other locations or just starting in practice. The average number of cases per surgeon per year was rounded down to the closest whole integer. Outcome among patients in each surgeon-volume group (1–5, 6–10, 11–15, and 15, with each group comprising approximately one fourth of the patients treated) were compared. Hospital volume effects were assessed by dividing the hospitals into groups based on the average number of breast cancer surgeries performed in the hospital per year. The average number of cases per hospital per year was rounded down to the closest whole integer. Outcome among patients in each hospital-volume group (1–34, 35–70, 71–125, and 125, with each group comprising approximately one fourth of the patients treated) were compared. Univariate differences in survival for prognostic factors were tested by using the log-rank test. Multivariate analysis was based on Cox regression analysis, which is also the basis for estimates of relative failure rates (relative risks; RR).²² The Pearson ² test²³ was used to test the association between surgeon and other prognostic factors. Because this was a retrospective nonrandomized study, hospital (SC vs. NSC), staging information, age, race, and SES were included in the primary analysis to adjust for the imbalance of these variables.

	RESULTS

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION REFERENCES

 
Comparison of Excluded and Included Cases
Table 1 lists the characteristics of the excluded and included patients. Excluded patients had more extensive disease, more node positivity, and larger tumors; were younger; were less likely to be white and more likely to be Hispanic; and were of lower SES than included patients. Patients excluded for missing data were significantly more likely to have been treated at an SC, suggesting a difference in data collection at these centers. Excluded patients also had significantly worse survival than included patients. However, excluded patients did not differ from included patients in the incidence of being treated by a surgical oncologist. This last observation, and the fact that the analyses of the association between surgeon type and survival were multivariate and adjusted for all of the other factors, suggests that bias due to these exclusions is negligible.

Patients excluded for having had no surgery were the most different from the included cases. Sixty percent of the patients who never underwent surgery had advanced disease that made surgery inappropriate. The reason for no surgery in the remaining patients was not documented but could include patient refusal or comorbid conditions that made surgery inadvisable. Whatever the reason for not undergoing surgery, these patients had the worst prognosis. Patients excluded for missing data were more similar to the included patients. The most common piece of missing data was the surgeon UPIN (54.2%), and this made it impossible to assess the effect of surgeon on outcome. Staging information (tumor size, nodal status, and extent of disease) was incomplete in 51.5% and was missing altogether in 6.2%. These patients were excluded because controlling for tumor stage was essential in the analyses.

Comparison of Cases by Surgeon
Table 2 lists the patient and tumor characteristics according to surgeon group (SO vs. non-SO). There were no statistically significant differences in tumor size between patients who were operated on by surgical oncologists and patients treated by other surgeons. Surgical oncologists treated more patients in the age group from 40 to 60 years than non-surgical oncologists (P < .0001). There was a slight difference in the extent of disease and nodal status between the two groups (P = .0187 and .0383, respectively); patients treated by non-surgical oncologists had more advanced disease. Patients who were white accounted for a larger proportion in the SO group than in the non-SO group (P < .0001). Compared with a non-surgical oncologist, a surgical oncologist was more likely to treat patients in an SC than in an NSC (P < .0001). Surgical oncologists tended to perform breast-conserving surgery more often than non-surgical oncologists (P = .0001). Thirty-one percent of surgical oncologists performed >15 breast cancer surgeries per year, whereas few non-surgical oncologists performed >15 per year (2.3%; P < .0001). Surgical oncologists worked in high-volume hospitals more frequently (44.4%) than non-surgical oncologists (16.4%; P < .0001). Because the differences in age, race, SES, extent of disease, and other variables listed in Table 2 could affect outcome, these were controlled for in the analyses.

View larger version (69K): [in this window] [in a new window]   FIG. 2. Relative failure rate by doctor volume and hospital volume based on the results from the multivariate analysis. The black bars represent all patients in each surgeon-volume group. Checkered bars represent all patients in each surgeon-volume group who were treated at hospitals treating 35 breast cancer patients per year; gray bars represent those patients treated at hospitals with 36 to 70 breast cancer patients per year; diagonal slash bars represent patients treated at hospitals with 71 to 125 breast cancer patients per year; and white bars represent patients treated at hospitals with >125 breast cancer patients per year.

View larger version (85K): [in this window] [in a new window]   FIG. 3. Overall survival from time of diagnosis, by surgeon type.

	DISCUSSION

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION REFERENCES

Previous studies have consistently shown a relationship between hospital volume and perioperative mortality for complex surgical procedures. Few studies have evaluated long-term survival, which is an equally valid measure of operative success for cancer surgery. Birkmeyer et al.²⁵ documented a 31% reduction in the risk of dying at 3 years after surgery for pancreatic cancer in a high-volume hospital compared with a low-volume hospital. Similarly, Bach et al.¹² showed increased 5-year survival after resection of lung cancer at a high-volume center. Relatively little attention has been paid to the quality of surgical care in the less technically challenging cancer surgeries. Schrag et al.¹⁴ documented a significant improvement in 5-year survival after colon cancer surgery at high-volume hospitals. They also reported increased use of adjuvant chemotherapy in stage III colon cancer patients, suggesting more appropriate use of adjuvant therapies at high-volume centers. Both Roohan et al.²⁰ and Morrow et al.²⁶ documented improved long-term survival after mastectomy at high-volume centers. Our data support this finding, with a 23% reduction in the risk of death at 5 years in hospitals treating >125 breast cancer patients per year.

There is little support in the literature for an effect of surgical experience (surgeon volume) or specialized training on outcome after cancer surgery. Latosinsky and Bear²⁷ showed no difference in local recurrence rates after mastectomy for node-positive breast cancer in patients treated by a surgical oncologist compared with a general surgeon. In contrast, Giacomantonia and Temple²⁸ reported improved sphincter preservation and local control rates in rectal cancer patients treated by a surgical oncologist compared with colorectal surgeons or general surgeons. In the only study evaluating the effect of surgeon specialization on outcome after breast cancer surgery, Gillis and Hole²⁹ found a 16% reduction in the risk of dying of breast cancer at 5 years in patients treated by a breast specialist compared with nonspecialists. In this study, a specialist was defined as a surgeon who worked in a dedicated breast clinic with a defined association with medical oncologists and pathologists, who organized and facilitated clinical trials, and who maintained a separate record of all breast cancer patients. There was no requirement for specialty training. They also did not control for the surgeon’s case volume. Our results confirm the effect of specialization on breast cancer outcome. Surgical oncologists achieved an 86% 5-year survival, compared with 79% for nonspecialists (P < .001), representing a 33% reduction in the risk of death.

Three possible explanations for an effect of surgeon specialization on long-term outcome include (1) pure volume effects (specialists tend to perform more of a specific type of surgery and therefore may have better results), (2) pure surgical skill (surgical oncologists have advanced training and are therefore better trained to perform cancer surgery and may perform a technically superior operation), or (3) more appropriate use of adjuvant therapies (surgical oncologists are trained not only in surgical technique, but also in the biology of cancer and the role of radiation and systemic therapies in cancer treatment and therefore may be more likely to refer patients appropriately). Our data do support a role for a surgeon’s case volume on long-term survival after surgery for breast cancer. Surgeons who performed >15 breast cancer surgeries per year achieved a 5-year survival of 84%, compared with the 84% of surgeons who performed 1 to 5 breast cancer surgeries per year, who had a 5-year survival of 75%. However, this is not the only reason for improved outcomes with specialization in SO. Surgical oncologists achieved a 36% reduction in the risk of death at 5 years when this was controlled for both hospital and surgeon volume, hospital, age, stage, and race.

Given the limitations of tumor registry data, there was no way to directly measure with any accuracy the role of surgical technique or the use of adjuvant therapies. However, it is possible to assess the relative effect of these two factors indirectly. If the explanation for the role of specialization is pure surgical talent, then the effect of specialization should be present at all hospitals. If, however, the effect of specialization is due to more appropriate use of adjuvant therapy, one would expect the effect of specialization to be more pronounced at an NSC, where patients would have to be actively referred for adjuvant therapy, than at a specialized cancer center, where a patient is more likely to be routinely considered for adjuvant therapy because of the culture of the institution. That is, the multidisciplinary care routinely available at a cancer center would balance out any effect of specialization. In fact, the effect of specialization in SO was more pronounced in NSCs compared with SCs (RR, .76 vs. .87, respectively). Although this difference was not statistically different, it suggests that the more appropriate use of multidisciplinary care by the surgical oncologist may be an important factor in the effect of specialization. Unfortunately, the small number of patients treated at SCs limits our ability to draw unequivocal conclusions from these data.

Long-term survival after surgery for breast cancer is not just due to the well-known risk factors of age, stage, race, and SES, but also to where the patient has her surgery and to who performs the surgery. Patients who undergo surgery at hospitals where >125 breast cancer surgeries are performed each year are more likely to achieve long-term survival. Similarly, patients who are operated on by surgeons who perform >15 breast cancer surgeries per year are more likely to achieve long-term survival. Finally, patients who are operated on by a surgical oncologist rather than a general surgeon are more likely to achieve long-term survival, perhaps, in part, because surgical oncologists are trained to understand the biology of the disease and to make more appropriate use of adjuvant therapies. These findings suggest that long-term survival in breast cancer can be improved by concentrating the care of these patients in high-volume centers where the patient will be treated by a surgeon who performs such surgeries regularly. Because of the volume of breast cancer patients and the relative rarity of specialists in SO, it is not reasonable to expect all breast cancer patients to be treated by surgical oncologists. However, surgical oncologists may be able to affect the outcome of all breast cancer patients by contributing to the education of general surgeons regarding the biology of breast cancer and the role of adjuvant therapies.

	ACKNOWLEDGMENTS

 
The acknowledgments are available online at www.annalssurgicaloncology.org.

	FOOTNOTES

 
We examined the effect of surgical and hospital specialization on outcome in breast cancer. Age, race, socioeconomic status, tumor size, surgeon specialization, and surgeon and hospital case volume, but not hospital specialization, affected survival after breast cancer surgery.

Received for publication June 24, 2002. Accepted for publication February 26, 2003.

	REFERENCES

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION REFERENCES

 

1. Choti MA, Bowman HM, Pitt HA, et al. Should hepatic resections be performed at high-volume referral centers? J Gastrointest Surg 1998; 2: 11–20.[CrossRef][Medline]
2. Begg CB, Cramer LD, Hoskins WJ, Brennan MF. Impact of hospital volume on operative mortality for major cancer surgery. JAMA 1998; 280: 1747–51.[Abstract/Free Full Text]
3. Glasgow RE, Showstack JA, Katz PP, Corvera CU, Warren RS, Mulvihill SJ. The relationship between hospital volume and outcomes of hepatic resection for hepatocellular carcinoma. Arch Surg 1999; 134: 30–5.[Abstract/Free Full Text]
4. Birkmeyer J, Siewers AE, Finlayson EV, et al. Hospital volume and surgical mortality in the United States. N Engl J Med 2002; 346: 1128–37.[Abstract/Free Full Text]
5. Rosemurgy A, Bloomston M, Serafini FM, Coon B, Murr MM, Carey LC. Frequency with which surgeons undertake pancreaticoduodenectomy determines length of stay, hospital charges, and in-hospital mortality. J Gastrointest Surg 2001; 5: 21–6.[CrossRef][Medline]
6. Simunovic M, To T, Theriault M, Langer B. Relation between hospital surgical volume and outcome for pancreatic resection for neoplasm in a publicly funded health care system. CMAJ 1999; 160: 643–8.[Abstract]
7. Sosa J, Bowman HM, Gordon TA, et al. Importance of hospital volume in the overall management of pancreatic cancer. Ann Surg 1998; 228: 429–38.[CrossRef][Medline]
8. Glasgow R, Mulvihill S. Hospital volume influences outcome in patients undergoing pancreatic resection for cancer. West J Med 1996; 165: 294–300.[Medline]
9. Lieberman M, Kilburn H, Lindsey M, Brennan MF. Relation of perioperative deaths to hospital volume among patients undergoing pancreatic resection for malignancy. Ann Surg 1995; 222: 638–45.[Medline]
10. Dudley R, Johansen KL, Brand R, Rennie DJ, Milstein A. Selective referral to high-volume hospitals: estimating potentially avoidable deaths. JAMA 2000; 283: 1159–66.[Abstract/Free Full Text]
11. Saettler E, Temple W. The surgeon as a prognostic factor in the management of pancreatic cancer. Surg Oncol Clin North Am 2000; 9: 133–42.[Medline]
12. Bach P, Cramer LD, Schrag D, Downey RJ, Gelfand SE, Begg CB. The influence of hospital volume on survival after resection for lung cancer. N Engl J Med 2001; 345: 181–8.[Abstract/Free Full Text]
13. Hillner B. Is cancer care best at high-volume providers? Curr Oncol Rep 2001; 3: 404–9.[Medline]
14. Schrag D, Cramer LD, Bach PB, Cohen AM, Warren JL, Begg CB. Influence of hospital procedure volume on outcomes following surgery for colon cancer. JAMA 2000; 284: 3028–35.[Abstract/Free Full Text]
15. Simons A, Ker R, Groshen S, et al. Variations in treatment of rectal cancer: the influence of hospital type and caseload. Dis Colon Rectum 1997; 40: 641–6.[CrossRef][Medline]
16. Marusch F, Koch A, Schmidt U, Pross M, Gastinger I, Lippert H. Hospital caseload and the results achieved in patients with rectal cancer. Br J Surg 2001; 88: 1397–402.[CrossRef][Medline]
17. Ellison L, Heaney J, Birkmeyer J. The effect of hospital volume on mortality and resource use after radical prostatectomy. J Urol 2000; 163: 867–9.[CrossRef][Medline]
18. Yao S-L, Lu-Yoa G. Population-based study of relationships between hospital volume of prostatectomies, patient outcomes, and length of hospital stay. J Natl Cancer Inst 1999; 91: 1950–6.[Abstract/Free Full Text]
19. Lerut T. The surgeon as a prognostic factor. Ann Surg 2000; 232: 729–32.[CrossRef][Medline]
20. Roohan P, Bickell NA, Baptiste MS, Therriault GD, Ferrara EP, Siu AL. Hospital volume differences and five-year survival from breast cancer. Am J Public Health 1998; 88: 454–7.[Abstract/Free Full Text]
21. SSO Mission Statement. 2002. Society of Surgical Oncology Web site. Available at: http://www.surgonc.org/sso/missframe.htm. Accessed May 13, 2003.
22. Kalbfleisch J, Prentice R. The Statistical Analysis of Failure Time Data. New York: Wiley, 1980.
23. Dixon WJ, Massey FJ. Introduction to Statistical Analysis. 3rd ed. New York: McGraw-Hill, 1969.
24. Bickell N, Chassin M. Determining the quality of breast cancer care. Do tumor registries measure up? Ann Intern Med 2000; 132: 705–10.[Abstract/Free Full Text]
25. Birkmeyer J, Warshaw AL, Finlayson SR, Grove MR, Tosteson AN. Relationship between hospital volume and late survival after pancreaticoduodenectomy. Surgery 1999; 126: 178–83.[Medline]
26. Morrow M, Stewart A, Sylvestar J, Bland K. Hospital volume predicts outcomes in breast cancer: a National Cancer Data Base (NCDB) study (abstract). Proc Am Soc Clin Oncol 2000; 19: 309.
27. Latosinsky S, Bear H. Do surgical oncologists achieve lower rates of loco-regional recurrence in node positive breast cancer treated with mastectomy alone? J Surg Oncol 2001; 78: 2–7.[CrossRef][Medline]
28. Giacomantonio C, Temple W. Quality of cancer surgery. Challenges and controversies. Surg Oncol Clin North Am 2000; 9: 51–60.[Medline]
29. Gillis C, Hole D. Survival outcome of care by specialist surgeons in breast cancer. A study of 3786 patients in the west of Scotland. BMJ 1996; 312: 145–8.[Abstract/Free Full Text]

This article has been cited by other articles:

				K. Holli, P. Hietanen, R. Saaristo, H. Huhtala, M. Hakama, and H. Joensuu Radiotherapy After Segmental Resection of Breast Cancer With Favorable Prognostic Features: 12-Year Follow-Up Results of a Randomized Trial J. Clin. Oncol., February 20, 2009; 27(6): 927 - 932. [Abstract] [Full Text] [PDF]

				A. M. Hogan and D. C. Winter Does Practice Make Perfect? Ann. Surg. Oncol., May 1, 2008; 15(5): 1267 - 1270. [Abstract] [Full Text] [PDF]

				H. A. Pass, S. V. Klimberg, and E. M. Copeland III Are "Breast-Focused" Surgeons More Competent? Ann. Surg. Oncol., April 1, 2008; 15(4): 953 - 955. [Full Text] [PDF]

				E. Morris, R. A. Haward, M. S. Gilthorpe, C. Craigs, and D. Forman The impact of the Calman-Hine report on the processes and outcomes of care for Yorkshire's breast cancer patients Ann. Onc., February 1, 2008; 19(2): 284 - 291. [Abstract] [Full Text] [PDF]

				A. B. Nattinger, P. W. Laud, R. A. Sparapani, X. Zhang, J. M. Neuner, and M. A. Gilligan Exploring the Surgeon Volume Outcome Relationship Among Women With Breast Cancer Arch Intern Med, October 8, 2007; 167(18): 1958 - 1963. [Abstract] [Full Text] [PDF]

				J. F. Waljee, S. Hawley, A. K. Alderman, M. Morrow, and S. J. Katz Patient Satisfaction With Treatment of Breast Cancer: Does Surgeon Specialization Matter? J. Clin. Oncol., August 20, 2007; 25(24): 3694 - 3698. [Abstract] [Full Text] [PDF]

				M. A. Gilligan, J. Neuner, X. Zhang, R. Sparapani, P. W. Laud, and A. B. Nattinger Relationship Between Number of Breast Cancer Operations Performed and 5-Year Survival After Treatment for Early-Stage Breast Cancer Am J Public Health, March 1, 2007; 97(3): 539 - 544. [Abstract] [Full Text] [PDF]

				M. A. Gilligan, J. Neuner, R. Sparapani, P. W. Laud, and A. B. Nattinger Surgeon Characteristics and Variations in Treatment for Early-Stage Breast Cancer Arch Surg, January 1, 2007; 142(1): 17 - 22. [Abstract] [Full Text] [PDF]

				A. Stark, G. Kucera, M. Lu, S. Claud, and J. Griggs Influence of health insurance status on inclusion of HER-2/neu testing in the diagnostic workup of breast cancer patients Int. J. Qual. Health Care, December 1, 2004; 16(6): 517 - 521. [Abstract] [Full Text] [PDF]

				J. S. O'Shea Editorial: Specialization in Surgical Oncology: Historical Perspectives Ann. Surg. Oncol., May 1, 2004; 11(5): 462 - 464. [Full Text] [PDF]

				E. M. Copeland III Breast Cancer: Specialists Do Make a Difference Ann. Surg. Oncol., July 1, 2003; 10(6): 589 - 590. [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Skinner, K. A. Articles by Sposto, R. Search for Related Content PubMed PubMed Citation Articles by Skinner, K. A. Articles by Sposto, R. Related Collections Surgery