Does where patients choose to have breast cancer surgery drive health care inequality?

Including patients as partners for making decisions about their medical treatments is an important aspect of patient-centered care. A new study from England examined choices that patients with breast cancer make when considering where to have surgery for their condition and assessed how policies that offer such choices might affect inequalities in the health care system. The findings are published in the journal Cancer.

For the study, investigators analyzed data from the National Health Service (NHS), the publicly funded health care system in the United Kingdom that offers patients with cancer the opportunity to select any hospital providing cancer treatment, and identified all women diagnosed with breast cancer from 2016 to 2018 who had breast-conserving surgery or a mastectomy.

Records showed that 22,622 of 69,153 patients undergoing breast-conserving surgery (32.7%) and 7,179 of 23,536 patients undergoing mastectomy (30.5%) bypassed their nearest hospital to receive surgery farther away from home. Women who were younger, without additional medical conditions, of white ethnic background, or lived in rural areas were more likely to travel to more distant hospitals.

Patients were more likely to be treated at hospitals classified as specialist breast reconstruction centers even if they personally were not undergoing breast reconstruction after surgery. Patients who had a mastectomy and immediate breast reconstruction were more likely to travel to hospitals that had surgeons with a strong media reputation for breast cancer surgery, and patients were less likely to travel to hospitals with shorter surgical waiting times.

Patients did not seem to make choices based on hospitals’ research activity, quality rating, breast re-operation rates (to remove additional cancer cells that were missed), or status as a multidisciplinary cancer center (where patients can receive all their care at one location).

The investigators noted that this separation—elderly patients, those with comorbidities, and those from ethnic minority backgrounds receiving care at their local hospital, while others travel to other hospitals and specialist centers—could further drive inequalities in access to quality care.

“As marginalized groups already face barriers to high-quality care, it is important for policy makers to consider measures that mitigate against the risks of increasing inequalities in access and outcomes, by for example providing free transport, accommodation, or even protection against loss of income,” said co-author Lu Han, Ph.D., of the London School of Hygiene & Tropical Medicine.

“Moreover, patients prefer to access information on the quality of breast cancer care of the hospitals in their region at the start of the management pathway when a diagnosis is sought. Such information should be easy to understand and presented in a format that can support the trade-offs that patients have to make.”