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Why do we need Breast Clinics?. Prof.Dr.M-R. Christiaens Multidisciplinair Borstcentrum. Incidence of Breast Cancer. Far most frequent cancer in female Still considerable mortality Belgium > 7000 new cancers each year Public health question - PowerPoint PPT Presentation
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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
0
10
20
30
40
50
60
70
80
90
100
No
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Tre
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Ea
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S E
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S E
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idla
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No
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N Ir
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urv
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l %
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?