Skip to main content
NCBI home page
The BMJ logoLink to The BMJ
. 1998 Oct 17;317(7165):1081. doi: 10.1136/bmj.317.7165.1081a

Medical and psychological effects of early discharge after surgery for breast cancer

Patients can be discharged on second postoperative morning

B J Mander 1, C Cunnick 1, M Daultrey 1, G C Wishart 1
PMCID: PMC1114079  PMID: 9774310

Editor—Bonnema et al studied medical and psychological effects of early discharge after surgery for breast cancer.1 Their results agree with our experience of early discharge in a district general hospital in the United Kingdom.2

To compare the care received by the two groups it is necessary to know what facilities were afforded to the early discharge group. These details were lacking in the paper. We routinely provide domiciliary physiotherapy (which is important after axillary surgery) and specialist breast counselling to ensure that our patients at home receive the same treatment as those in hospital.

We are unsure why the authors chose four days as the discharge time for their early discharge group. After a pilot study we now routinely discharge all patients suitable for domiciliary care on the second postoperative morning. Ninety per cent of patients thought that this was an appropriate postoperative stay. Analysis of use of analgesia showed that patients required only oral analgesia at this time even after combined mastectomy and axillary surgery. What benefit is gained by the extra 48 hours in hospital?

The technique used by the authors to assess patient satisfaction is unusual. They recorded patients’ preference for a longer or shorter stay rather than satisfaction with the treatment they received. The 37% who recommended early discharge without having experienced it may have been reflecting dissatisfaction with their own experience rather than perceived satisfaction with a different discharge policy. We found that 90% of patients thought that our early discharge facility was excellent.

No significant difference in postoperative psychosocial variables was noted by Bonnema et al at one and four months after surgery. At one month after surgery the early discharge group will have spent about 88% of the month at home and the delayed discharge group 72%. Any effect of prolonged hospital stay will have been masked by the time the measurements were recorded. Analysis at day 9 postoperatively—the median time of leaving hospital for the delayed discharge group—would have maximised the chance of any effect of early discharge being picked up.

Early discharge after surgery for breast cancer is feasible, safe, and popular with patients. Inevitably there will be some patients for whom it is not feasible because of lack of social support or comorbidity. For most, however, it enables them to recover within the comfort of their own home and family. We would encourage others to look into ways of establishing this service.

References

  • 1.Bonnema J, van Wersch AMEA, van Geel AN, Pruyn JFA, Schmitz PIM, Paul MA, et al. Medical and psychological effects of early discharge after surgery for breast cancer: randomised trial. BMJ. 1998;316:1267–1271. doi: 10.1136/bmj.316.7140.1267. . (25 April.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Mander BJ, Qureshi T, Strong L, Wishart GC. The feasibility, safety, acceptability and cost analysis of early discharge following surgery for breast cancer. Br J Surg. 1998;85:S20. [Google Scholar]
BMJ. 1998 Oct 17;317(7165):1081.

Follow up period to assess psychological morbidity was too short

A D Purushotham 1

Editor—Bonnema et al’s randomised trial fails to answer the questions that the authors sought to answer. Firstly, the two groups being compared contained a mixed cohort of patients undergoing breast conserving surgery or modified radical mastectomy. The authors have therefore made the fundamental assumption that women undergoing either procedure have the same postoperative complication rate and experience the same degree of psychological morbidity. They should have been stricter in their inclusion criteria and recruited only patients who underwent the same surgical procedure. This would have made their results more meaningful.

The concept of keeping patients in hospital for 9-12 days postoperatively is archaic. In our practice, which probably reflects practice in the rest of the United Kingdom, the mean postoperative hospital stay is in the region of four days, with drains being removed on day 5, irrespective of the volume of fluid drained.

One of the authors’ aims was to address the complication rate after early discharge. In their discussion they state that “the number of patients in this study was too small to detect a difference of 5% in rates of wound complication” and that recruitment of 800 patients, which is what would have been required, would not have been “feasible in this type of research.” Why?

Any study examining shorter hospital stay must include a detailed analysis of costs, with a health economist participating to calculate in-hospital and community costs. This is particularly important for the United Kingdom, where NHS funding is central.

The follow up period to assess psychological morbidity is too short. At three months patients may be undergoing adjuvant treatment, locoregional radiotherapy, and systemic chemotherapy, which add to their morbidity. It is essential that such studies are designed to assess psychological morbidity at completion of treatment to provide a more meaningful result. In this study a further set of questionnaires to be completed at one year would have been necessary.

These issues are currently being addressed in a randomised trial in the Western Infirmary, funded by the Scottish Office, which will complete recruitment at the end of 1998. Results from this study should clarify all the issues raised above.

Footnotes

adp1s@clinmed.gla.ac.uk

References

  • 1-1.Bonnema J, van Wersch AMEA, van Geel AN, Pruyn JFA, Schmitz PIM, Paul MA, et al. Medical and psychosocial effects of early discharge after surgery for breast cancer: randomised trial. BMJ. 1998;316:1267–1271. doi: 10.1136/bmj.316.7140.1267. . (25 April.) [DOI] [PMC free article] [PubMed] [Google Scholar]
BMJ. 1998 Oct 17;317(7165):1081.

Home situation is important for early discharge

John D Sheehan 1

Editor—Bonnema et al’s conclusion that early discharge from hospital after surgery for breast cancer is safe and is well received by patients should be challenged.2-1 Their assertion that “our randomised study has proved that shortening the length of time a patient spends in hospital after surgery for breast cancer has no adverse effects” is invalid. Altogether 139 of 173 patients were enrolled in the study. Ten of the 34 excluded women had an “unsatisfactory home situation.” Do the authors contend that sending these women home early from hospital would have no adverse effects? Surely the conclusion should be that early discharge from hospital is safe and well received by a selected group of women after surgery for breast cancer.

Another point concerns the psychosocial variables. The patients randomly allocated to the short hospital stay scored higher on scales measuring depression before surgery than did those allocated to a long stay. The authors contend that this finding may be due to the uncertainty about the experimental treatment. But one would expect uncertainty to lead to anxiety and not depression. Furthermore, the authors state that the difference in depression scores disappeared after surgery but then seem to contradict this by adding that there was no decrease in mood disturbance in the short stay group at four months.

References

  • 2-1.Bonnema J, van Wersch AMEA, van Geel AN, Pruyn JFA, Schmitz PIM, Paul MA, et al. Medical and psychosocial effects of early discharge after surgery for breast cancer: randomised trial. BMJ. 1998;316:1267–1271. doi: 10.1136/bmj.316.7140.1267. . (25 April.) [DOI] [PMC free article] [PubMed] [Google Scholar]
BMJ. 1998 Oct 17;317(7165):1081.

Authors’ reply

J Bonnema 1, A M E A van Wersch 1, A N van Geel 1, J F A Pruyn 1, P I M Schmitz 1, M A Paul 1, T Wiggers 1

Editor—In the Netherlands, discharging patients one or two days after surgery for breast cancer is not yet common and length of stay is determined by the duration of wound drainage. We believe that the reduction in stay to four or five days and discharge with a drain in situ are important advances. Other studies, including the pilot study of Mander et al, show that the length of admission of the long stay group still varies between seven and nine days,3-1,3-2 as in our study. Practices regarding hospital discharge after surgery will probably continue to change rapidly, and we are therefore interested to read of the practice at Purushotham’s hospital.

We did not assess patients’ satisfaction with treatment by asking them about it directly, as the answers would have been influenced by social desirability. In addition to our published findings we asked patients about several aspects of early discharge, such as being at home with the drain; the answers confirmed that the procedure was well accepted (unpublished data).

We recorded psychosocial variables one and four months after surgery, being interested in learning whether being at home earlier influenced psychosocial rehabilitation, and not in measuring a difference between being at home or in hospital. We do not agree that we should have measured psychological morbidity again one year after surgery; any effect of early discharge is unlikely to be picked up at this time, as so many stressful effects of treatment will have occurred.

Our suggestion that depression before surgery in short stay patients may be due to uncertainty remains speculative. Anxiety and depression are known, however, to be highly correlated. The difference in depression scores between short and long stay patients disappeared after surgery, which means only that mood disturbance was not significantly different between the two groups.

We do not agree with Purushotham that our inclusion criteria biased the results. Production of serous fluid after breast conserving treatment and after modified radical mastectomy does not differ,3-3 and there is no strong evidence for differences in psychological outcomes between groups who receive these treatments.3-4

Sheehan is right that early discharge is safe for and well received by most patients with breast cancer, except for a small group in whom it is not feasible because of lack of social support. In our institutes it would have taken more than eight years to acquire 800 patients for our study, which we do not consider realistic in a study on discharge policies.

References

  • 3-1.Holcombe C, West N, Mansel RE, Horgan K. The satisfaction and savings of early discharge with drain in situ following axillary lymphadenectomy in the treatment of breast cancer. Eur J Surg Oncol. 1995;21:604–606. doi: 10.1016/s0748-7983(95)95133-4. [DOI] [PubMed] [Google Scholar]
  • 3-2.Mander BJ, Qureshi T, Strong L, Wishart GC. The feasibility, safety acceptability and cost analysis of early discharge following surgery for breast cancer. Br J Surg. 1998;85:S20. [Google Scholar]
  • 3-3.Bonnema J, van Geel AN, Ligtenstein DA, Schmitz PIM, Wiggers T. A prospective randomized trial of high versus low vacuum drainage after axillary dissection for breast cancer. Am J Surg. 1997;173:76–79. doi: 10.1016/S0002-9610(96)00416-3. [DOI] [PubMed] [Google Scholar]
  • 3-4.Fallowfield LJ, Hall A, Maguire GP, Baum M. Psychological outcomes of different treatment policies in women with early breast cancer outside a clinical trial. BMJ. 1990;301:575–580. doi: 10.1136/bmj.301.6752.575. [DOI] [PMC free article] [PubMed] [Google Scholar]

Articles from BMJ : British Medical Journal are provided here courtesy of BMJ Publishing Group

RESOURCES