West Midlands Cancer Intelligence Unit NHSBSP Surgical QA Data for the Year of Screening 1 April 2002 to 31 March 2003 Dr Gill Lawrence and Professor Jan

West Midlands Cancer Intelligence Unit

NHSBSP Surgical QA Data for the Year of Screening

1 April 2002 to 31 March 2003

Dr Gill Lawrence

and

Professor Jan Frisell

on behalf of

ABS at BASO


Acknowledgements

• Mr Hugh Bishop• Mr James Bristol• Mr Mark Kissin• Dr Gill Lawrence• Mrs Julietta Patnick• Ms Jacquie Reed

• Ms Nicola Richmond• Prof Paul Sauven• Dr Matthew Wallis• Dr Jackie Walton• Mrs Margot Wheaton

The BASO Breast Audit Group

would like to extend their thanks to all

NHS and ABS at BASO staff who contributed to the

2002/03 ABS at BASO Breast Audit


Acknowledgements

ABS at BASO • Surgical QA Co-ordinators• Ms Lucy Davies

Breast Screening QA Reference Centres• QA Directors• QA Co-ordinators• QA Data Managers

Screening Services• Screening Office Managers• Surgeons

Regional Cancer Registries West Midlands Cancer Intelligence Unit


Setting the scene

Number of cancers and consultant surgeons in the UK NHSBSP


Regions supplying data

Total Cancers

Cancer Detection

Rate

Region(per 1000 screened)

N East, Yorks & Humber 1457 7.2East Midlands 930 7.5East of England 1245 7.6London 1139 7.3South East (East) 863 7.0South East (West) 738 6.7South West 1053 8.0West Midlands 1034 6.9North West 1403 7.4Wales 660 8.4Northern Ireland 216 6.8Scotland 855 6.9United Kingdom 11593 7.3

***

* boundary changes

***

* name changes


0

1

2

3

4

5

6

7

8

9

10

11

Ca

nce

r d

ete

ctio

n r

ate

Non-invasive & Micro-invasive Invasive Unknown invasive status

Cancer detection rates 2000-03

UK - all cancers6.9 per 1000

UK - non inv/micro 1.5 per 1000


Screening surgical caseload

Surgical specialisation most advanced in West Midlands and Northern Ireland

In North West, 60 women were under the care of more than one consultant surgeon

London and East of England were unable to provide a reason for low caseload for more than 20 surgeons

2000/01 2001/02 2002/03

Consultant surgeons in the UK NHSBSP 419 439 472

Median screening caseload 17 18 18

% women treated by surgeons with caselaod 20+ 86 85 86

No. surgeons with unexplained low caseload (<10) 25 52 55


Pre-operative diagnosis

X


0

10

20

30

40

50

60

70

80

90

100N

E, Y

& H

E M

idla

nds

E of

Eng

land

Lond

on

S E

ast E

S E

ast W

Sou

th W

est

W M

idla

nds

Nor

th W

est

Wal

es

N Ir

elan

d

Sco

tland

Pre

-op

era

tive

dia

gn

osi

s ra

te (

%)

C5 only C5 & B5 B5 only

UK 91%

Min std 80%

Pre-operative diagnosis rate


0

10

20

30

40

50

60

70

80

90

100

Pre

-op

era

tive

dia

gn

osi

s ra

te (

%)

Min std 80%

Pre-operative diagnosis rate

Target 90%


Pre-operative diagnosis rate (7 year comparison)

0

10

20

30

40

50

60

70

80

90

100

1996/97 1997/98 1998/99 1999/00 2000/01 2001/02 2002/03

Pre

-op

era

tive

dia

gn

osi

s ra

te (

%)

C5+/-B5 C5 only C5&B5 B5 only


Wales

Scotland

0

10

20

30

40

50

60

70

80

90

100

2000/01 2001/02 2002/03

Pre

-op

era

tive

dia

gn

osi

s ra

te (

%)


0

10

20

30

40

50

60

70

80

90

100

2000/01 2001/02 2002/03

Pre

-op

era

tive

dia

gn

osi

s ra

te (

%)


3 year comparison

North West0

10

20

30

40

50

60

70

80

90

100

2000/01 2001/02 2002/03

Pre

-op

erat

ive

dia

gn

osi

s ra

te (

%)


81%

89%

N Ireland

0

10

20

30

40

50

60

70

80

90

100

2000/01 2001/02 2002/03

Pre

-op

era

tive

dia

gn

osi

s ra

te (

%)


89%

88%

86%

91%

86%

92%

Non inv


0

10

20

30

40

50

60

70

80

90

100N

E, Y

& H

E M

idla

nds

E of

Eng

land

Lond

on

S E

ast E

S E

ast W

Sou

th W

est

W M

idla

nds

Nor

th W

est

Wal

es

N Ir

elan

d

Sco

tland

Inva

sive

Sta

tus

afte

r su

rger

y (%

)

Invasive Micro-invasive Non-invasive No Surgery Unknown

Invasive status after B5a (Non-invasive) core biopsy

UK 24%

33%38%


0

10

20

30

40

50

60

70

80

90

100

Inva

sive

Sta

tus

afte

r su

rge

ry (

%)

Invasive Micro-invasive Non-invasive No Surgery Unknown

Invasive status after B5a (Non-invasive) core biopsy

UK 24%


Repeat visits to achieve a pre-operative diagnosis

0

10

20

30

40

50

NE,

Y &

H

E M

idla

nds

E of

Eng

land

Lond

on

S E

ast E

S E

ast W

Sou

th W

est

W M

idla

nds

Nor

th W

est

Wal

es

N Ir

elan

d

Sco

tland

Pre

-op

era

tive

dia

gn

osi

s ra

te

(%)

2+ visits Unknown

UK 2+ visits 12%


Diagnostic open biopsies


0.0

0.5

1.0

1.5

2.0

2.5

1996/97 1997/98 1998/99 1999/00 2000/01 2001/02 2002/03

Op

en

bio

psy

ra

te (

pe

r 10

00 s

cre

en

ed

)

Benign Malignant

Open biopsy rates

4749 2734M + 2015B

2919 1018M + 1901B


Open biopsy rates per 1000 women screened

0.00

0.50

1.00

1.50

2.00

2.50

2000/01 2001/02 2002/03Op

en

bio

psy

ra

te (

pe

r 10

00 s

cre

en

ed

)

Benign Malignant

0.00

0.50

1.00

1.50

2.00

2.50

2000/01 2001/02 2002/03Op

en

bio

psy

ra

te (

pe

r 10

00 s

cre

en

ed

)Benign Malignant

North West Wales

Highest rates in UK in 2000/01


Type of surgical treatment provided to non-invasive and

invasive breast cancers


0

10

20

30

40

50

60

70

80

90

100

Typ

e o

f tr

ea

tme

nt

(%)

Conservation surgery Mastectomy No surgery Unknown

Treatment for non & micro-invasive cancers 2002/03

UK 69%


0

10

20

30

40

50

60

70

80

90

100

Co

nse

rva

tio

n s

urg

ery

(%

)Treatment for non & micro-invasive cancers 2000-03

UK 69%


High grade multi-focal 28

Large (30+mm) multi-focal 6

Large (30+mm) high grade 90

Large (30+mm) unknown grade 3

Unknown size high grade 54

Unknown size & grade 64

Total* 239

Non-invasive cancers treated by conservation surgery

*counts each cancer once only

Sloane Project data items

grade size

margin status


0

5

10

15

20

25

30

35

40

45

50

55

60

Ma

ste

cto

my

rate

(%

)

Treatment for all invasive cancers 2000-03

UK 28%

Yellow line through the Midlands (East and West)

Blue above this line (Scotland, N Ireland, NEYH, North West, Wales)

Red below this line (E of England, London, South East (E & W), South West)

4xNEYH


0

5

10

15

20

25

30

35

40

45

50

55

60

Ma

ste

cto

my

rate

(%

)

Treatment for invasive cancers <15mm 2000-03

UK 20%

Yellow line through the Midlands (East and West)

Blue above this line (Scotland, N Ireland, NEYH, North West, Wales)

Red below this line (E of England, London, South East (E & W), South West)

3xNEYH


Mastectomy rates according to tumour size

Mastectomy rates are lower if whole size is taken into consideration

Presence of DCIS increases mastectomy rate

Invasive size

Whole size

50+ mm 81% 88%

20-<50mm 45% 36%

15-<20mm 25% 21%

<15mm 19% 15%


Mastectomy rates according to tumour size

0

5

10

15

20

25

30N

E, Y

& H

E M

idla

nds

E of

Eng

land

Lond

on

S E

ast E

S E

ast W

Sou

th W

est

W M

idla

nds

Nor

th W

est

Wal

es

N Ir

elan

d

Sco

tland

Ma

ste

cto

my

rate

(%

)

Invasive size <15mm Whole size <15mm

14% immediate reconstruction

Reconstructionaudit

UK 15% whole size

UK 19% invasive size

*

***


Lymph nodes and invasive grade


0

2

4

6

8

10

12

14

16

18

20

22

24

26

28

30

32

34

No

da

l st

atu

s u

nkn

ow

n (

%)

Invasive cancers with nodal status unknown

UK 5.3%10 units complete nodal

information

7/8 London units >2x UK average

1 unit complete nodal info

for 2000-03


Insufficient nodal information for invasive cancers

No. %N East, Yorks & Humber 1134 48 28 76 6.7East Midlands 720 27 27 54 7.5East of England 954 83 30 113 11.8London 862 102 51 153 17.7South East (East) 652 29 31 60 9.2South East (West) 596 22 17 39 6.5South West 849 42 25 67 7.9West Midlands 811 11 22 33 4.1North West 1141 74 61 135 11.8Wales 532 5 13 18 3.4Northern Ireland 163 23 1 24 14.7Scotland 672 13 14 27 4.0

UK 9086 479 320 799 8.8

RegionInsufficient nodal

informationTotal

invasive cancers

Unknown nodal status

-ve with <4 nodes

* excludes sentinel nodes

*


02468

10121416182022242628303234

Insu

ffici

ent

no

dal

inf

orm

atio

n (%

)

Unknown nodal status Negative <4 nodes (excl sentinel)

Insufficient nodal information for invasive cancers

UK 8.8%


0

10

20

30

40

50

60N

E, Y

& H

E M

idla

nds

E o

fE

ngla

nd

Lond

on

S E

ast E

S E

ast W

Sou

th W

est

W M

idla

nds

Nor

th W

est

Wal

es

N Ir

elan

d

Sco

tland

Nod

al s

tatu

s (%

)

Nodal status known Unknown if nodes obtained

Non-invasive cancers with known nodal status

UK 26%

41% mastectomiesUK 29%


0

10

20

30

40

50

60

70

80

90

100

B5a +/- C5 B5b +/- C5 B5c/u C5 only No C5/B5

Nod

al s

tatu

s kn

own

(%)

81

25

4

21

13

Nodal status and pre-operative history

Why take nodes for B5a? conservatively treated

non-invasive cancers


0

10

20

30

40

50

60

70

80

90

100

Gra

de

(%

)

I II III Not assessable Unknown1 unit no data

Invasive grade


0

10

20

30

40

50

60

70

80

90

100

NP

I G

rou

p (

%)

EPG GPG MPG1 MPG2 PPG

NPI


Repeat therapeutic operations

90% of cancers with single lesions

(excluding multi-focal tumours and those

with extensive DCIS) should not require a further operation to ensure complete

excision


0

5

10

15

20

25N

E, Y

& H

E M

idla

nds

E of

Eng

land

Lond

on

S E

ast E

S E

ast W

Sou

th W

est

W M

idla

nds

Nor

th W

est

Wal

es

N Ir

elan

d

Sco

tland

Re

pe

at

Op

era

tio

n R

ate

(%

)

Invasive Non-invasive

Repeat operation rates

UK 14% invasive

UK 16% non-invasive


Repeat operations - possible scenarios

B5a (non invasive) invasive after surgeryInvasion not predicted by pre-operative diagnosis

- repeat operation to obtain nodes

C5 nodes not taken at first operation1

Margins not clear- repeat operation conservation or

mastectomy

2

3

Expected tumour component

Small B5b (invasive) with unexpected DCIS

Additional nodal procedure

Insufficient no. obtained at 1st operation

Therapeutic clearance after large no. +ve

Clearance after +ve sentinel node

4


B5b (Invasive) : invasiveafter surgery - 6743 cases

Cons. &Ax

Mx. & Ax Cons. Mx.

Cons.

Mx.

Mx.

4154 cases, 62% 1458 cases, 22% 230 cases, 3% 56 cases, 1%

355 cases, 5% 214 cases, 3%

34 cases, 1%

Mx. & Ax

46 cases, 1%

17 (0%) Unknown,9 (0%) Ax only,

29 (0%) Other no AX,87 (1%) Other Ax at 1st op,54 (1%) Other Ax at later op

B5b invasive after surgery

5% no Ax

84% 1 operation inc Ax

12% repeat operation


0

10

20

30

40

50

60

70

80

90

100

NE,

Y &

H

E M

idla

nds

E of

Eng

land

Lond

on

S E

ast E

S E

ast W

Sou

th W

est

W M

idla

nds

Nor

th W

est

Wal

es

N Ir

elan

d

Sco

tland

Ax

illa

ry s

urg

ery

(%

)

First surgery Later surgery

Nodal status for B5b invasive after surgery

UK 94% first operation1% repeat operation

31% no Ax surgery


C5, no B5, invasive - 1126 cases

Cons. &Ax

Mx. & Ax Cons. Mx.

Cons.

Mx.

720 cases, 64% 185 cases, 16% 39 cases, 3% 19 cases, 2%

49 cases, 4% 29 cases, 3%

6 cases, 1%

15 cases, 1%

Mx. Mx. & AxCons. &

AxAx

15 cases, 1%

14 cases, 1%

8 cases, 1%

Ax.

6 (1%) Unknown,6 (1%) No Surgery,

2 (0%) Ax only,3 (0%) Other no AX,

7 (1%) Other Ax at 1st op,3 (0%) Other Ax at later op

C5 only invasive cancers80% 1 operation inc Ax


5% no Ax


0

10

20

30

40

50

60

70

80

90

100

NE,

Y &

H

E M

idla

nds

E of

Eng

land

Lond

on

S E

ast E

S E

ast W

Sou

th W

est

W M

idla

nds

Nor

th W

est

Wal

es

N Ir

elan

d

Sco

tland

Ax

illa

ry s

urg

ery

(%

)


Nodal status C5 only invasive after surgery


23% no Ax surgery

16% no Ax surgery


B5a (Non-invasive) : invasive aftersurgery - 548 cases

Mx. & AxCons. &

AxCons. Mx.

Mx.

129 cases, 24% 124 cases, 23% 53 cases, 10%

16 cases, 3%

10 cases, 2%

8 cases, 1%

Cons.

Ax 6 cases, 1%

Cons. &Ax

68 cases, 12%

63 cases, 11%

37 cases, 7%

Ax. Mx & Ax

7 cases, 1%

Cons.

Mx

7 cases, 1%2 (0%) Unknown,

2 (0%) Other no AX,4 (1%) Other Ax at 1st op,6 (1%) Other Ax at later op

Mx & AxCons. &

Ax

3 cases, 1%

3 cases, 1%

B5a invasive cancers46% 1 operation inc Ax

14% no Ax

34% Ax at repeat operation



0

10

20

30

40

50

60

70

80

90

100

NE,

Y &

H

E M

idla

nds

E of

Eng

land

Lond

on

S E

ast E

S E

ast W

Sou

th W

est

W M

idla

nds

Nor

th W

est

Wal

es

N Ir

elan

d

Sco

tland

Ax

illa

ry s

urg

ery

(%

)


Nodal status B5a invasive after surgery


60% at repeat op

24% no Ax surgery

31% no Ax surgery

70% at first op


Adjuvant therapies

Which pathways were followed?

How long did it take to get there?

What combinations of treatments were given? ?


Data completeness for RT, CT, HT start dates

0

10

20

30

40

50

60

70

80

90

100N

E, Y

& H

E M

idla

nds

E of

Eng

land

Lond

on

S E

ast E

S E

ast W

Sou

th W

est

W M

idla

nds

Nor

th W

est

Wal

es

N Ir

elan

d

Sco

tland

Da

ta c

om

ple

ten

ess

(%

)

RT, CT, HT complete RT, CT complete

84% some data supplied (77% last year)

76% RT, CT complete

UK 72% RT, CT, HT complete


0

10

20

30

40

50

60

70

80

90

100N

E, Y

& H

E M

idla

nds

E of

Eng

land

Lond

on

S E

ast E

S E

ast W

Sou

th W

est

W M

idla

nds

Nor

th W

est

Wal

es

N Ir

elan

d

Sco

tland

ER

no

t d

on

e o

r u

nkn

ow

n (

%)


Unknown ER status

UK 63% non-invasiveUK 9% invasive


Data completeness for PgR status

0

10

20

30

40

50

60

70

80

90

100N

E, Y

& H

E M

idla

nds

E of

Eng

land

Lond

on

S E

ast E

S E

ast W

Sou

th W

est

W M

idla

nds

Nor

th W

est

Wal

es

N Ir

elan

d

Sco

tland

Pg

R s

tatu

s kn

ow

n (

%)

All cancers ER Negative

UK 30% known all cancers UK 50% known

for ER –ve cancers


0

10

20

30

40

50

60

70

80

90

100N

E, Y

& H

E M

idla

nds

E of

Eng

land

Lond

on

S E

ast E

S E

ast W

Sou

th W

est

W M

idla

nds

Nor

th W

est

Wal

es

N Ir

elan

d

Sco

tland

Ce

rb-B

2/H

ER

-2 s

tatu

s kn

ow

n (

%)

Data completeness for Cerb-B2/HER-2 status

UK 11%


Times to first treatment and from first treatment to

adjuvant therapy


Median days between therapies

Shading:orange10% above UK, green 10% below UK

RT RT CT CT

(1 op) (>1 op) (1 op) (>1 op)

N East, Yorks & Humber 30 27 78 106 42 63

East Midlands 32 28 62 90 38 78

East of England 28 27 90 114 31 63

London 35 30 92 119 40 90

South East (East) 43 40 95 127 41 80

South East (West) 22 25 104 129 33 62

South West 34 30 67 88 43 78

West Midlands 33 22 67 103 37 58

North West 33 28 76 131 40 61

Wales 22 23 72 101 43 66

Northern Ireland 28 14 69 111 37 35

Scotland 29 26 56 87 35 64

UK 30 27 73 103 38 66

Final surgery to...

Diag surgery

Therap surgery

Region

Assessment to...


0

5

10

15

20

25N

E, Y

& H

E M

idla

nds

E of

Eng

land

Lond

on

S E

ast E

S E

ast W

Sou

th W

est

W M

idla

nds

Nor

th W

est

Wal

es

N Ir

elan

d

Sco

tland

HT

be

fore

fir

st s

urg

ery

(%

)

Hormone Therapy before first surgery

UK 10% (12% last year)


Propositions for discussion

1 Women treated with conservation surgery should normally receive radiotherapy

Women with ER negative, node positive invasive tumours should normally receive chemotherapy 2

3Hormonal Therapy (eg. Tamoxifen) is only beneficial to women with ER positive tumours and ER negative PgR positive tumours


0

10

20

30

40

50

60

70

80

90

100N

E, Y

& H

E M

idla

nds

E of

Eng

land

Lond

on

S E

ast E

S E

ast W

Sou

th W

est

W M

idla

nds

Nor

th W

est

Wal

es

N Ir

elan

d

Sco

tland

Wit

ho

ut

RT

(%

)


Proportion of cancers not receiving radiotherapy

UK 11% invasive UK 52%

non-invasive

49% high grade 30% 15+mm 38% high grade

44% 15+mm

81 invasive 20+mm conservativelytreated cancers


0

10

20

30

40

50

60

70

80

90

100N

E, Y

& H

E M

idla

nds

E of

Eng

land

Lond

on

S E

ast E

S E

ast W

Sou

th W

est

W M

idla

nds

Nor

th W

est

Wal

es

N Ir

elan

d

Sco

tland

Wit

h C

T (

%)

ER Negative Node Positive ER Negative Node Negative

ER -ve invasive cancers receiving chemotherapyUK 85% node +ve

UK 49% node -ve

Only 28 ER -ve node +ve cancers did not receive CT

84% of the ER -ve node -ve cancers with CT were Grade III


0

10

20

30

40

50

60

70

80

90

100N

E, Y

& H

E M

idla

nds

E of

Eng

land

Lond

on

S E

ast E

S E

ast W

Sou

th W

est

W M

idla

nds

Nor

th W

est

Wal

es

N Ir

elan

d

Sco

tland

Wit

ho

ut

HT

(%

)


ER +ve cancers not receiving hormonal therapy

527 ER +ve cancers (9%) did not receive HT

UK 33% non-invasive

UK 7% invasive


0

5

10

15

20

25

30

35

40N

E, Y

& H

E M

idla

nds

E of

Eng

land

Lond

on

S E

ast E

S E

ast W

Sou

th W

est

W M

idla

nds

Nor

th W

est

Wal

es

N Ir

elan

d

Sco

tland

Wit

h H

T (

%)

0

ER -ve cancers receiving hormonal therapy

30/45 (67%) ER -ve PgR +veand 49/360 (14%) ER -ve PgR -ve

cancers received HTUK 16%


Survival analyses for screen-detected cancers diagnosed

1st April 1992 - 31st March 1998


Relative survival for invasive cancers

85

90

95

100

0 1 2 3 4 5 6 7 8 9 10

Years

Re

lati

ve S

urv

iva

l (%

)

1992/93 1993/94 1994/95 1995/96 1996/97 1997/98

10 year survival for 1992/93 cases, 87.8%

5 year survival for 1997/98 cases, 95.8%


50

55

60

65

70

75

80

85

90

95

100

EPG GPG MPG1 MPG2 PPG

Rel

ativ

e S

urv

ival

(%)

1992/93-1994/95 1993/94-1995/96 1994/95-1996/97 1995/96-1997/98

5 year relative survival and NPI

59% of cases with known NPI are EPG/GPG


Download the audit (booklet and presentation)

from

www.wmpho.org.uk/wmciu

and

www.cancerscreening.nhs.uk


Documents

West Midlands Cancer Intelligence Unit NHSBSP Surgical QA Data for the Year of Screening 1 April 2002 to 31 March 2003 Dr Gill Lawrence and Professor Jan