Why do we need Breast Clinics?

Prof.Dr.M-R. ChristiaensMultidisciplinair Borstcentrum

Incidence of Breast Cancer

• Far most frequent cancer in female• Still considerable mortality

• Belgium > 7000 new cancers each year

• Public health question Quality in diagnosis, treatment and

quality of life does matter!!!!

The ‘Quality Concept’

• “I recognise it when I see it”

• What constitutes ‘quality’?• How can we measure ‘quality’?• How can we improve ‘quality’?

Eusoma Guidelines

• The Requirements of a Specialist Breast Unit, 2002

• Quality assurance in the diagnosis of breast disease

• Quality control in the locoregional treatment of breast cancer

• Guidelines on endocrine therapy of breast cancer

• The curative role of radiotherapy in the treatment of operable breast cancer

• Prophylactic surgery

Guidelines

• NHS – BAS0 Guidelines

• The Requirements of a specialist Breast Unit R.W. Blamey et. Eur J Cancer 2002, 36, 2288-2293

• Resolution European Parliament, 2003

• KB Oncology Centers, 2003 – Specialised care programs

• KCE : Breast Cancer Screening; report vol.IIA, 2005

• Oncology college ………2007?

• EUREF – European Guidelines for Quality Assurrance in Breast Cancer Screening and Diagnosis, 4th ed.;

The requirements of a specialist unit, first revision European Communities, 2006

• EORTC BCG – EUSOMA – Europa Donna EBCC-5 Nice 2006, Consensus Document

• Guidelines on the standards for the training of specialised health professionals dealing with breast cancer - EUSOMA

(to be published)

Eusoma Objectives for Breast Units

• To make available for all women in Europe a high quality specialist Breast Service

• To define standards for such a service

• To recommend that a means of accreditation and audit of Breast Units be established in order that units providing this service would be recognisable to patients and to purchasers as being of high quality

Eusoma Accreditation of Breast UnitsBasic Criteria• A single integrated Unit

• Sufficient cases to allow effective working and continuing expertise

• Care by breast specialists in all the required disciplines

• Working in multidisciplinarity in all areas

• Providing all necessary services: genetics, prevention, diagnosis, treatment, advanced disease and palliation

• Patient support

• Data collection and Audit

Eusoma Accreditation of Breast UnitsBasic CriteriaA single integrated Unit

• Single geografical entity?

– Allow multidisciplinary working– The same MDT– The same protocols– MD case management meetings– Single dataset– Audited as one Unit

Eusoma Accreditation of Breast UnitsBasic CriteriaSufficient cases to allow effective working

and continuing expertise

• Case load 150 newly diagnosed patients/year

• ‘Surgeon’: 30 operations / year

Type of Hospital

• Teaching vs Non-Teaching Hospitals– Survival: odds ratio 1.46; p= 0.0009

Bassnet; Eur J Cancer 1992

– BCS in 72 vs 65%– RT after BCS in 82 vs 73 %

Ruhee Chaudhry, CMAJ 2001

• Participation in Clinical Trials and survival

Case load • >< 30 new BC procedures/y: Survival RR: 0.85

< 10% have > 150 new cases/year1/3 have < 25 new cases/year

• 60% ‘multidisciplinary breast clinics’: 2/week – 1/year

Sainsbury; Lancet 1995 Harries; The breast 1997

• Training and Experience – Completeness of excision of NPL: p=0.0001

experience: 20 operations during study period

– BCT vs Mastectomy: p=0.0003 (Dixon; Brit J Surg 1996)

– Learning curve (Sentinel node procedure!)

Full Therapeutic options - Multidisciplinarity

Case load per surgeon and outcome …D.M. Ingram et al; The Breast 2005

Treatment 20+ / y <20 / y OR (95% CI)

BCS 53.3 36.71.96 (1.64–2.33)

ALN-procedure

88.7 87.81.08 (0.83–1.41)

Adjuvant RT 50.0 30.62.06 (1.70–2.50)

Adjuvant CT 29.2 20.91.47 (1.14–2.89)

Adjuvant HT 57.3 60.20.88 (0.75–1.06)

Case load per surgeon and outcome …D.M. Ingram et al; The Breast 2005

YearSurgical caseload

4-year survival 5-year survival

1989 <20 82% (78–85) 75% (71–80)

20+ 86% (81–90) 81% (75–86)

1994 <20 84% (80–88) 79% (76–85)

20+ 89% (86–92) 85% (81–88)

1999 <20 78% (71–85) NA

20+ 90% (88–92) NA

Hospital case load - extrapolated

Number of cases /y Number of Hospitals % women

<25 30 8

25-75 53 48

75-150 26 20

> 150 8 24

Total 117 100

CM Files 2006

Univariate analysis of Survival according to Case LoadWomen 50 to 69 year - stage II

CM Files 2006

Variations in relative survivalInvasive breast cancer

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5 year survival 8 year survival

5yr UK 94.1%8yr UK 90.9%

West Midlands Cancer Intelligence Unit

BASO Breast Group

Radiotherapy after BCS, generally with axillary clearance (BCSRT) in all women (pN0, PN+)

EBCTCG

Breast cancer mortality in trials of Polychemotherapy versus Not, entry age 50-69

Eusoma Accreditation of Breast UnitsBasic Criteria

Care by breast specialists in all the required

disciplines

Multidisciplinarity in all areas

Radiotherapy according to type of hospital - Stratification for age and stage of disease

CM Files 2006

Treatment pattern according to case load – stratification for age (50-69) and stage of disease

CM Files 2006

Eusoma Accreditation of Breast UnitsBasic Criteria

Providing all necessary services: genetics,prevention, diagnosis, treatment, advanceddisease and palliation

Written, updated and evidence based protocols

‘Oncologisch Handboek’

‘Individual patient decisions’

Care program with protocol • Participation in Screening

• Diagnosis: mammo, US, MRI; FNAC / CNB / VACNB / Stereotactic proceduresPathology

• Benign Breast Disease

• Malignant Disease – all stages

• Supportive groups – Oncorevalidation – e.g.

• Reconstructive surgery

• Organised follow-up

• Familial and Hereditary Breast Cancer Counseling

• Palliative care

• Teaching

• Research: clinical – translational – basic (blood-tumor bank)

Eusoma Accreditation of Breast UnitsBasic CriteriaPatient support for all patients - all

stagesInformationAdvocateCoachBuddy Guide

Reduce anxiety♀56 y; left mastectomy and ALND

Eusoma Accreditation of Breast UnitsBasic CriteriaData collection and Audit • Q.T. Data collection on treatment of screen

detected lesions, Ponti A, et al. European guidelines for quality assurance in

breast screening and diagnosis, 3rd ed., European Communities 2001

• MOC – Cancer registration

• Communication of results

Breast Units can use QT to managepatient care, file relevant information

on cases and evaluate their own activity

QC in locoregional treatment- Eusoma GuidelinesTargets

Pre-treatment tripel assessment

• Palpable BC > 95%

• FNAC/CNB in BC > 90%

• NPBC, +FNAC/CNB > 80%

QA in diagnosis – Eusoma guidelines

Targets

Surgical aspects

• Wire < 1cm NPL > 90%• One operation NPL > 95%• Benign lesions, < 30 g >

90%• B:M ratio 0.5 : 1• No FS, < 10 mm and µ-cal > 95%

QC in locoregional treatment –Eusoma guidelinesTargets

Locally Advanced Breast cancer• Definition:

> 5 cm; skin involvement; chest wall (muscle or skeletal) involvement; fixed axillary lymphnodes; pN+ apex; T4d

• Aim:– Down staging– OS????

• Outcome measure:> 80% multimodality treatment:

RT, chemo, hormonal and surgical

PatientPartnerchildren

Radiologist

Pathologist

Breast SurgeonGynaecologist

Medical Oncologist

Radiation Oncologist

Nurses Ward

Nurses

Operation theatre

Nurses Out patient clinic

Plastic surgeon

Nucleair MedGenetic Counseling

Palliative team AnaesthesiaFysiotherapyPsychologist

Nurses Day care unit

GP

BCNSupport Groups

ProsthesisCosmetic advice

Wigs

Trial Nurse

Receptionist

Logistics

Trainees BTB

Eusoma Accreditation of Breast UnitsR.W.Blamey and L. CataliottiEur J Cancer, July 2006

• Need faced by patients and referring doctors

• Genuine claims to designate oneselves specialist units

• Need for a process of accreditation

• Voluntary ( EUREF Accreditation also voluntary!)

     

 

Survey of European Breast Cancer ServicesDirectory of specialist breast cancer services initiated in collaboration with EUSOMA, aiming at providing patients and physicians with information on centres of expertise

http://www.cancerworld.org/ebcs/en/bs/Directory.asp

Belgium: 6 Luxemburg: 1France: 2 United Kingdom:1Germany: 3 Netherlands: 1Hungary: 1 Spain: 2Italy: 5 Switzerland: 1Portugal: 1 Slovenia: 1

October 2006

Facilitate physicians’ acceptance ofguidelines by not imposing liability for

thefailure to follow guidelines withoutdetermining thestandard of care

The Belgian way?