Breast Cancer Research and Treatment

, Volume 175, Issue 3, pp 585–594 | Cite as

Explaining variation in quality of breast cancer care and its impact: a nationwide population-based study from Slovenia

  • Gaber PlavcEmail author
  • Ivica Ratoša
  • Tina Žagar
  • Vesna Zadnik
Clinical trial



To assess and explain variation in quality of care in breast cancer patients and estimate its impact on disease outcome.


The Slovenian National Cancer Registry database and clinical records of 1053 women with unilateral primarily non-metastatic invasive breast cancer diagnosed in 2013 were reviewed in this retrospective analysis. Quality care was defined as care fully compliant with quality indicators (QI) defined by European Society of Breast Cancer Specialists (EUSOMA). Multivariate logistic regression was used to determine the predictors of receiving quality care. Differences in overall survival (OS) and event-free survival (EFS, relapse, or progression of disease or death considered an event) based on adherence to QI were analyzed using Kaplan–Meier method and Cox models.


Younger age, no comorbidities, and HER2-negative tumor were associated with increased odds ratios for receiving quality care, whereas tumor stage and type of hospital had no significant association. Median follow-up was 54.5 months. Not receiving quality care resulted in an increased risk of dying [hazard ratio (HR) 1.68; 95% confidence interval (CI) 1.06–2.66; p = 0.026]. Difference in EFS between two groups was significant after adjusting for case mix and type of hospital (HR 1.80; 95% CI 1.29–2.52; p = 0.001) but disappeared when type of treatment was added into the model (HR 1.30; 95% CI 0.89–1.90; p = 0.178).


Observed comorbidity and age bias in delivering quality breast cancer care could be medically justifiable, whereas observed deviations dependent on HER2 status are puzzling. Complete adherence of treatment to quality indicators resulted in better OS.


Breast neoplasm Quality indicators EUSOMA Health services Survival 



We would like to thank Andraž Perhavec, MD, PhD, for a critical review of the article.


The work was supported in part by ERA-NET within the framework of the call on “Translational research on tertiary prevention in cancer patients” (TRANSCAN), with funding from Ministry of Education, Science and Sport (MIZS), Slovenia.

Compliance with ethical standards

Conflict of interest

The authors declare no further conflicts of interest.

Ethical approval

The study protocol was approved by the Protocol Review Board and Ethics Committee of the Institute of Oncology Ljubljana.

Informed consent

Informed consent for using their data for retrospective study purposes at the start of their treatment was obtained from all individual participants included in the study.


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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Radiation OncologyInstitute of Oncology LjubljanaLjubljanaSlovenia
  2. 2.Department of Epidemiology and Cancer RegistryInstitute of Oncology LjubljanaLjubljanaSlovenia

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