France is confronted with a shortage of medical oncologists. This problem creates many disparities in cancer management. Given that a growing number of regions are deprived of physicians, they are currently reconsidering ways of making healthcare available where it is needed. Access to oncologists varies considerably from one region to another, suggesting that breast cancer management is not optimal. The heterogeneity of care structures and medical practices brings about health inequalities . In an attempt to deal with this problem, cancer networks have been created across the country. The aim of these networks is to offer patients equitable and good quality cancer services. Moreover, the organization of cancer networks seems to favor standardized practices, based on research data . In this context, a new organization was put in place in our region to promote more widespread healthcare service, with equal access for all patients, regardless of their geographical location. The regional impact of this new organization from a quality perspective was assessed before and after its implementation.
The two populations studied present similar characteristics, except for the number of lymph nodes involved at diagnosis (N0 on TNM classification). In the “after” period, we observed more patients without lymph nodes (69.1%). This result can be explained by the fact that systematic screening allowed us to detect breast cancer earlier, as previously reported by other authors [16–18]. In a German study, almost 18% of all breast cancer cases were identified through a screening examination . Benson et al. showed that the incidence of small (<1 cm) invasive breast cancers without axillary lymph node involvement has been increasing because of the wider use of mammographic screening . However, although the N0 rate increased, this does not necessarily mean that study patients are at lower risk of progression. Indeed, the percentage of patients with a risk of ten-year progression >40% was identical in both periods.
The new organization of care in our region did not change the profile of patients treated in the peripheral centres. These centres can offer oncology treatment to patients near their place of residence, since access to necessary healthcare facilities has been maintained or improved. However, high-risk patients, whose condition was likely to deteriorate, tended to be treated mainly in the reference centre during the second period, as reflected by the increase in the rates of negative estrogen receptor tumors and SBR grade 3 tumors observed in the reference centre.
One of the feared consequences of creating a new regional healthcare delivery structure was that patient management might be delayed due to the mandatory multidisciplinary meetings. It was unclear whether mobile team management would delay treatment, because the patients were further away from the reference centre, or whether the quality of patient management might be compromised. However, our results show that these fears may have been unfounded, as management did not appear to be negatively affected by the introduction of a new structure for cancer delivery.
Although the results are not significant, efficient coordination tends to improve quality criteria by favouring faster breast cancer management, with a reduced time between surgery and adjuvant chemotherapy. It also allows patients to be treated with the appropriate dose-density. Time to treatment in our study was comparable to data from the national cancer institute (INCA), at 5.6 ± 3.6 weeks versus 5.9 ± 2.1 weeks in 2010 . By contrast, the rate of delayed treatment was far lower in our study, with only 1.1% experiencing a delay before treatment, versus 42.2% in the national study. For the most part, these results can be explained by successful multidisciplinary collaboration among professionals and by local community-based management.
The new organization had no effect on 24-month PFS. Follow-up in our study was not long enough to assess patient prognosis (two years). Indeed, Ng et al. reported that, despite the existence of a correlation between 2-year PFS and 5-year overall survival, the correlation was not strong enough to be used as a predictor .
At an economic level, this study did not estimate the loss of occupational activity and related social contributions due to breast cancer, which might be substantial in this disease. Indeed, the economic impact of breast cancer is high [23–25]. The overall cost of managing local breast cancer was not significantly modified by the new organization, estimated at around €3,500. In the new healthcare structure, patients can benefit from similar quality cancer services at a similar cost. The use of taxanes led to a significant increase in the cost of chemotherapy between the two periods among patients who were treated with chemotherapy. However, the number of hospital admissions for complications tended to decrease, which subsequently reduced the overall cost. Finally, the new organization made it possible for patients to benefit from the addition of taxanes to the standard chemotherapy regimen, while limiting the overall cost. Moreover, travel costs to the reference centre can be avoided with the new set-up, and patients can be treated more comfortably in peripheral centres near their homes. Despite the shortage of oncologists, physicians manage to limit transport costs. Thus, we can suppose that the quality of life of these patients was improved with reduced travel time and cost, but further studies are warranted to confirm this hypothesis.
This study has some limitations. The major limitation is the before-and-after design, which precludes any conclusions as to whether changes in care are due to the implementation of a new regional organization for healthcare delivery. Secondly, does not assess patient satisfaction. Moreover, another major limitation is the change in practices between study periods. Between 2007 and 2010, the methods for treating patients with local breast cancer were optimized. Fewer patients received chemotherapy (7% decrease), but the chemotherapy used was more intensive, with taxane molecules. This observation is not the result of implementing a new regional organization for cancer care delivery. The greater use of taxanes over the past few years has been described in the literature, with a number of trials addressing the benefit of adding a taxane (paclitaxel or docetaxel) to an anthracycline-based adjuvant chemotherapy regimen [26–30]. However, under the new regional structure for cancer care delivery, management is now standardized throughout the region of Franche-Comté and in line with national and international recommendations.