Assurance of Timely Access to Breast Cancer Diagnosis and Treatment by a Regional Breast Health Clinic Serving Both Urban and Rural-Remote Communities
Round 1
Reviewer 1 Report
This is a very interesting manuscript showing the importance of establishing centralized breast health clinics. WI have a few major concerns:
1) Figure 3: While there was significant overall decrease in wait time, the break-down of diagnostic and treatment individually, only had a minimal (statistically significant) benefit from establishing RFBHC. Can the authors think of a way to tweak around the model to enhance better wait-time advantage both at diagnostic and treatment intervals? This can be explained in discussion section.
2) Figure 4: A major advantage from RFBHC seems to be from PI, IB and PC components. This makes me think, that the BHC has a better centralized equipment technical services, but the expert medical (pathology and physician) services are still limited. Can the authors comment if their model has dedicated physicians only for breast cancer expertize or, are they using general hem/oncologists? Most of the BHCs (atleast in the US) have a dedicated team of oncologists who only see breast cancer patients. The authors should comment on the availability (and feasibilty) of dedicated breast cancer-only-oncologists at their center.
3) A very important aspect I would like to see in their study is the demographic stratification of their BHC. Is their an impact on the wait-time for rural/urban or below-poverty/middle income/high income groups. It is a well-known fact that there is inequity in healthcare services to economically disadvantaged groups. Can the authors comment if their BHC addressed this issue?
4) I wonder why the authors did not use patient satisfaction as a metric? What are the patient satisfaction metrics from there pre-postBHC establishment.
Author Response
Point 1: Figure 3: While there was significant overall decrease in wait time, the break-down of diagnostic and treatment individually, only had a minimal (statistically significant) benefit from establishing RFBHC. Can the authors think of a way to tweak around the model to enhance better wait-time advantage both at diagnostic and treatment intervals? This can be explained in discussion section
Response 1:
Dear Reviewer,
Thank you for your comment. The focus of the RFBHC is to improve breast cancer diagnostic wait times rather than treatment wait times (lines 50-52, 265-267). We believe the 21.3 day diagnostic wait time reduction for RFBHC patients when compared to pre-RFBHC patients (lines 166-167) is substantial. Currently the RFBHC is not involved in the treatment of breast cancer. However, as we explained in lines 270-272, the independent introduction of the central surgical referral system, established at the same time as the RFBHC, likely contributed to shorter treatment wait times for RFBHC patients when compared to pre-RFBHC patients.
Point 2: Figure 4: A major advantage from RFBHC seems to be from PI, IB and PC components. This makes me think, that the BHC has a better centralized equipment technical services, but the expert medical (pathology and physician) services are still limited. Can the authors comment if their model has dedicated physicians only for breast cancer expertize or, are they using general hem/oncologists? Most of the BHCs (atleast in the US) have a dedicated team of oncologists who only see breast cancer patients. The authors should comment on the availability (and feasibilty) of dedicated breast cancer-only-oncologists at their center.
Response 2: Thank for you for this comment. We updated our introduction (lines 69-77) to provide more detail on the physicians attached to the RFBHC. The RFBHC addressed deficiencies in the breast cancer diagnostic pathway through a system change rather than expertise change. Unfortunately, in a Canadian community of our size, it is not feasible to have a dedicated team of physicians who only treat breast cancer attached to the clinic. Please let us know if you would like to see more discussion of this.
Point 3: A very important aspect I would like to see in their study is the demographic stratification of their BHC. Is their an impact on the wait-time for rural/urban or below-poverty/middle income/high income groups. It is a well-known fact that there is inequity in healthcare services to economically disadvantaged groups. Can the authors comment if their BHC addressed this issue?
Response 3: We agree that it would be interesting to determine if the RFBHC improved the inequalities between rural/urban and below-poverty/middle/upper income groups, however this data is not available for our study. Our data was originally collected as part of a quality improvement project, and did not include patients’ address or socioeconomic status. We do have data on whether patients are from Kamloops or from outside of Kamloops, however we don’t feel that this is an accurate measure of urban/rural residency. We noted these limitations in our discussion (lines 294-297).
Point 4: I wonder why the authors did not use patient satisfaction as a metric? What are the patient satisfaction metrics from there pre-postBHC establishment.
Response 4: We agree that patient satisfaction is an important metric. A second branch of our study looked at patient experience. We added results from a patient experience survey to our manuscript, and updated our abstract (lines 23-24, 31-32), introduction (lines 88-89), methods (lines 147-154), results (lines 232-237), discussion (lines 244-245) and references (lines 471-474) to reflect this change. Unfortunately, we don’t have patient experience data from the pre-RFBHC or Traditional Stream groups.
Reviewer 2 Report
Dear Editor,
"Assurance of Timely Access to Breast Cancer Diagnosis and Treatment by a Regional Breast Health Clinic Serving both Urban and Rural-Remote Communities" has been reviewed. It is well written in general terms, but there are some English spelling errors, Some copyediting of the grammar and word choice is needed and there are other devices (MRI, ultrasound, optical imaging) available and reported in other studies for breast cancer imaging and treatment, what differentiates this device compared to others? it is necessary to mention different imaging techniques for breast cancer imaging and treatment in this study,
Yours sincerely
Author Response
Point 1: Assurance of Timely Access to Breast Cancer Diagnosis and Treatment by a Regional Breast Health Clinic Serving both Urban and Rural-Remote Communities" has been reviewed. It is well written in general terms, but there are some English spelling errors, Some copyediting of the grammar and word choice is needed
Response 1:
Dear Reviewer,
Thank you for your comments. We reviewed the manuscript to correct any overlooked spelling and grammatical errors.
Point 2: there are other devices (MRI, ultrasound, optical imaging) available and reported in other studies for breast cancer imaging and treatment, what differentiates this device compared to others? it is necessary to mention different imaging techniques for breast cancer imaging and treatment in this study,
Response 2: We added details on the imaging devices used by the RFBHC in our introduction (lines 64-65), which are typical of those used by Canadian centers to diagnose breast cancer. The RFBHC used the same imaging devices as the pre-RFBHC and Traditional stream groups, no new imaging devices were utilized by the clinic.
Reviewer 3 Report
The importance of equity of access to cancer care is an increasingly highlighted aspect of cancer care- this paper clearly demonstrates the impact of a specialist breast unit and pathway orchestration in a an area with a population density that will be relevant in many countries - as such it could be used an an exemplar for other healthcare organisations to establish similar services in their countries. The paper would benefit from additional discussion of the statistics used including more detail on the program used (line 132) . The study limitations are clearly outlined it would be interesting to perform a survey of patient and provider experience at this time as a quality improvement initiative and to see if further refinements could be made to their service
Author Response
Point 1: The importance of equity of access to cancer care is an increasingly highlighted aspect of cancer care- this paper clearly demonstrates the impact of a specialist breast unit and pathway orchestration in a an area with a population density that will be relevant in many countries - as such it could be used an an exemplar for other healthcare organisations to establish similar services in their countries. The paper would benefit from additional discussion of the statistics used including more detail on the program used (line 132) .
Response 1:
Dear Reviewer,
Thank you for your comments. The corresponding author may have created confusion by attributing “software” to one of the study authors in author contributions; this has been corrected. No novel software was developed for this study, however standard statistical software was used by our statistician for the analysis as described in the methodology section (lines 136-140). Please let us know if the reviewer would like further discussion of the statistics and program used.
Point 2: The study limitations are clearly outlined it would be interesting to perform a survey of patient and provider experience at this time as a quality improvement initiative and to see if further refinements could be made to their service
Response 2: We agree that patient satisfaction is an important metric. A second branch of our study looked at patient experience. We added results from a patient experience survey to our manuscript, and updated our abstract (lines 23-24, 31-32), introduction (lines 88-89), methods (lines 147-154), results (lines 232-237), discussion (lines 244-245) and references (lines 471-474) to reflect this change. Unfortunately, we don’t have patient experience data from the pre-RFBHC or Traditional Stream groups.
Round 2
Reviewer 1 Report
No further comments.
