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Review of organizational factors related to care offered to women with breast cancer.

Recent years have seen a growing interest in quality of care as a means of improving medical care while controlling the rising costs of health services, practice variations, and inappropriate or useless interventions (1). The structure, process, and outcomes of care have all been the focus of investigation, using either implicit or explicit criteria (2, 3). Although outcomes are the ultimate end results by which the value of medical interventions can be assessed, they are also considered less sensitive and sometimes even irrelevant in this context (2, 3). This is certainly true with regard to breast cancer, where some major therapeutic innovations, such as the shift toward locoregional management with breast preservation, have not necessarily led to improvement in such an important outcome of treatment as survival (4). In 1985, Donabedian (5) described the "epidemiology of quality" and the main predictors of optimal care among characteristics of the client, the attending physician, and the hospital of treatment. Using the same conceptual framework, the current review was undertaken to identify variables associated with the pattern of care offered to women with breast cancer, in an era where important therapeutic developments have taken place. Our ultimate goal was to assess outputs as well as outcomes of treatment for breast cancer and their determinants and to promote evidence-based decision making in the organization of health services in this area. This review should provide clues to be used by health planners and public health practitioners for breast cancer control, while also taking into account these patients' concerns and expectations. The abundance of the literature on health services in breast cancer and the uncertainty about the optimal treatment settings to be implemented both underscore the relevance of this critical appraisal.