Tracy, not wanting to knock the US achievements in screening, prevention and protocol (bravo!) but the only Euro-continental participant is Germany. What about France, the Netherlands and all the rest? Also, the lack of comparable outcomes measures means that these sorts of studies cannot focus closely on "what produces the best outcome" but "what is easy to measure" - which is why you get immunization rates, screening rates, compliance with policy/protocol, overall survival rates for various sorts of cancer and accessibility.

I was thinking of something different. In medical circles, centers of excellence are those that devise new treatments or achieve astounding results by getting very good in a small niche whether it be hip joint revisions, bone cancer or whatever, and publish their results in peer-reviewed journals. If the results are that good, the word spreads. Then patients who are in trouble and can afford it may be motivated to travel to that center to make sure they are getting the very best and to have a chance to participate in experimental treatments that may or may not work, but at least offer hope. By the above measures, as you note, centers attracting extra-sick patients may seem to have shocking results if you don't consider the denominator. But physicians all over the world will hold such centers in high regard. Why? Because these are the places from which new treatments and new hope can flow. These are the sorts of facility to which a foreign millionaire might travel, not necessarily to a center that does good breast cancer screening and follows existing protocols to the letter, if you see what I mean.