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Reexamining the Relationship of Breast Cancer Hospital and Surgical Volume to Mortality: An Instrumental Variable Analysis. Med Care 2015 Dec;53(12):1033-9 PMID: 26492213 PMCID: PMC4648647

Pubmed ID



OBJECTIVE: To reexamine the relationship of hospital and surgical volume to all-cause and breast cancer-specific mortality, taking into account the potential selection bias in patients treated at high-volume centers or by high-volume surgeons.

DATA SOURCES: Elderly (65+) women with early-stage, incident breast cancer surgery in 2003.

STUDY DESIGN: A population-based, prospective survey study.

METHODS: Two-stage, instrumental variable regression models.

PRINCIPAL FINDINGS: Women treated in high-volume hospitals were significantly less likely to die of any cause by 5 years after surgery, even after adjustments for self-selection and a number of other factors. The relationship was larger and more significant for breast cancer-specific mortality. Although the general pattern of better mortality outcomes held for moderately sized hospitals, the relationships were not statistically significant. In contrast, there was no relationship of surgeon volume with all-cause or breast cancer-specific mortality.

CONCLUSIONS: Hospital volume, but not surgeon volume, is associated with better survival among women with breast cancer. The magnitude of the potential improvement was substantial and comparable with the benefit conferred by many systemic therapies. These findings highlight the importance of accounting for patient self-selection in volume-outcome analyses, and provide support for policy initiatives aimed at regionalizing breast cancer care in the United States.

Author List

Pezzin LE, Laud P, Yen TW, Neuner J, Nattinger AB


Purushottam W. Laud PhD Professor in the Institute for Health and Equity department at Medical College of Wisconsin
Ann B. Nattinger MD, MPH Associate Provost, Professor in the Medicine department at Medical College of Wisconsin
Joan Neuner MD, MPH Associate Professor in the Medicine department at Medical College of Wisconsin
Liliana Pezzin PhD, JD Professor in the Medicine department at Medical College of Wisconsin
Tina W F Yen MD, MS Professor in the Surgery department at Medical College of Wisconsin


2-s2.0-84948121438   10 Citations

MESH terms used to index this publication - Major topics in bold

Aged, 80 and over
Breast Neoplasms
Cancer Care Facilities
Health Status
Hospitals, High-Volume
Neoplasm Staging
Outcome Assessment (Health Care)
Prospective Studies
Residence Characteristics
Socioeconomic Factors
United States
jenkins-FCD Prod-297 dff1a717c492f00bf6291286365f1f4fe95208f1