As shown in many studies, being treated in a specialized medical centre or by a high-volume surgeon is an independent prognostic factor for survival in patients with cancer, breast cancer particularly 1 2 3 4 5 6 7 8 9 . Moreover it is now well known that the socio-economic level is also an independent factor of survival in women with breast cancer 10 11 12 13 . For some cancers, socioeconomic deprivation and the distance to reference care centres have been studied and shown to be predictive factors of access to specialized care 14 15 , but to our knowledge this has not been studied for breast cancer. In addition, there are disparities between a country’s socioeconomic level and rural/urban distribution: in the United States of America and the United Kingdom, city centres tend to be occupied by the most deprived people, whereas the wealthy live in suburbs around the cities. In France, it is the other way around: the most privileged classes live in the centre of big cities, whereas the most deprived people live further away in the suburbs or in rural towns. This study is one of the first to analyse the impact of surgeons’ experience on survival and the link between social characteristics and access to specialized surgeons.

In our population, we first studied the impact on survival of being operated on by a specialized breast cancer surgeon. We then determined whether the educational, social and economic environment of patients, the fact of living in a town or in the countryside, and the distance to the nearest reference care centre, independently of individual characteristics, such as age or stage at diagnosis, had an impact on being treated by one of the specialized breast cancer surgeons, all of whom work in one of the two reference care centres of the district.

Since the Calman and Hile report in 1995 18 , the trend in European countries is to concentrate care supply in specialized cancer-care centres. In France, the Cancer Plan and the ministerial decree of March 29^th 2007, which established the minimal threshold for cancer operations illustrates this intention to concentrate cancer care. This policy decision was based on the hypothesis that patients are more likely to receive high-quality treatment if their surgeon has experience in operating on their particular cancer. This hypothesis is confirmed in our study: survival in patients operated on by one of the highest-volume breast cancer surgeons was significantly higher than in others.

Our study has several limits. First of all, the survival analysis did not take into account all of the possible confounding factors. Moreover, in order to simplify the analysis, we established a threshold to define two classes of surgeons: we used a threshold of 100 operations, as we had done several survival analyses using various categories of reference surgeons: there was no significant difference among surgeons who had operated on more than 100 breast cancers, but there was a significant difference between the above surgeons and those who had done fewer than 100 operations, among whom there was no significant difference either.

In addition, in practice, among the 92 surgeons who had operated on at least one breast cancer between 1998 and 2008, the eight who had performed the most operations, in a regular manner during their years of practice, and were known to be surgeons of the department specialized in breast cancer surgery, were those who had done more than 100 operations each, the ninth and the following surgeons had all done less than 100 operations over the study period.

Nonetheless, we adjusted our multivariate survival analysis for age, year of diagnosis, TNM stage, comorbidities and the circumstances of the diagnosis, in order to minimize the number of confounding factors. In contrast, our analysis was not adjusted for other cancer treatments, notably chemotherapy and radiotherapy, which also have an impact on survival. But, very often, surgery is the first step in the treatment, and the surgeon or the centre the patient is referred to is the gateway to the rest of the treatment. Access to one of these surgeons is therefore a prognostic factor in breast cancer. More than a quarter of our patients was not referred to and did not see a specialized surgeon.

The results of our study suggest that remoteness from a reference care centre, meaning remoteness from a regional capital, and a socioeconomically deprived environment have an impact on access to surgeons specialized in breast cancer. The most deprived patients and patients who lived far from their regional reference care centre for breast cancer were less likely to be operated on by a high-volume surgeon. Our study showed that the probability of being operated on by a specialized surgeon is inversely proportional to the socio-economic level of the place of residence as determined by the IRIS. Though the difference was not statistically significant for the 2nd and 3rd quintiles in comparison with patients of the most affluent Townsend Index quintile, patients of the two most deprived quintiles were respectively 1.5 and 1.6 times more likely to be operated on by a non-specialist surgeon.

The same was true for remoteness; there was no significant difference between patients who lived less than 10 minutes by car, and those who lived between 10 and 20 minutes by car from one of the two reference treatment centres of the Cote d’Or. However, patients who lived 20 to 35 and more than 35 minutes away from a reference care centre were respectively 1.8 and 2.6 times more likely to be operated on by a non-specialist surgeon than were patients living closest to the centres. In our study, the likelihood of being treated by a high-volume surgeon decreased with distance from the specialized centre. This means that unfavourable geographical and social characteristics have to be considered as potential predictive factors of a less than optimal surgical result, of potential recurrence and worse survival, as suggested by a French report on the risk of being less well treated in a low-volume hospital 19 . Moreover, patients who are less likely to be treated in reference centres are generally the same as those who are less likely to receive optimal overall disease management. Geographical and socioeconomic disparities remained significant even after adjustment for TNM status and age at diagnosis. Our findings showed a trend towards the results of similar studies about cancer treatment in reference centres, especially for colorectal cancer 14 15 .

Another interesting point is that women who were diagnosed within the context of a screening program were significantly more likely to be operated on by a high-volume surgeon than were patients who were diagnosed on clinical symptoms. This parameter was included in the analysis as an adjustment variable to study the hypothesis that patients with disadvantageous geographic and socio-economic characteristics were less likely to be referred to a high-volume surgeon because they were less likely to take part in mass screening programs. The result underpins the hypothesis that women who take part in mass screening programs for breast cancer are indeed more likely to be operated on by a specialized surgeon and this independently of remoteness and socio-economic level of their place of residence.

This raises other hypotheses on cancer detection and treatment patterns that need to be explored in specific studies.

Though we showed that socioeconomic deprivation and remoteness were independent predictors of access to a specialized surgeon, and as such, could be linked to survival, we were unable to explain why underprivileged patients or those living far from reference care centres were less likely to be referred to specialized surgeons. Though it can be understood that patients who live far from a reference care centre may prefer to be treated locally rather than travel, it is difficult to explain why the most deprived patients, independently of the distance, were less likely to receive specialized care.

Nevertheless, social and geographical disparities with regard to access to care for patients with breast cancer remain, and these disparities can affect the chances of survival. Improvements need to be made in the quality of care in non-reference care centres, or in the distribution of specialized care centres around the country, to avoid aggravating these differences.

The authors declare that they have no competing interests.

JG and PA conceived and designed the study; JG, TSD, SO and MLP participated in the quality control and data acquisition; JG and OD performed statistical analyses and interpreted the data; JG and TSD wrote the manuscript. All the authors read and approved the final manuscript.