breastscreen aotearoa an independent review - Ministry of Health

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eferral to a surgeon can only be done after the woman has discussed the options withher GP.7.3 The budget for BSA as a whole allows for District Health Boards to be refundedby the NSU for the costs of treating women in their public hospitals, but since thetreating clinicians there may not be aware which of their patients have come via BSA,it is not clear how often this funding is claimed. The impression was gained that BSApatients get "lost" among non- BSA breast cancer patients, and although this does notnecessarily affect the quality of their care it certainly makes it difficult to retrieveinformation about their management.7.4 The revised Quality Standards for Treatment, (still in draft form), require the LeadProvider to ensure that women referred for treatment have access to a specialistmultidisciplinary team, including oncologists and ideally within a designated breastunit, and that the team follows evidence-based guidelines on management of womenwith breast cancer. The Breast Section of the Royal Australasian College of Surgeonsproduces such guidelines, and has set up a system for auditing the treatments used bysurgeons who voluntarily agree to send in structured forms about all their breastcancer patients. Where a patient who lives in a remote area opts to go to a "lowvolume facility" (less than 150 breast cancer cases treated per annum) that facilityshould develop formal links with a larger unit and collaboration with regionaloncologists. One possible means of encouraging achievement of the target ofproviding evidence-based multidisciplinary treatment would be for the Lead Providersto emphasise to newly diagnosed breast cancer patients the advantages of treatment bya multidisciplinary breast team which participates in the Royal Australasian Collegeof Surgeons Breast Cancer Audit.7.4.1 Recommendation The information given to women about where they mayreceive free treatment should identify by name those surgeons who areparticipating in the RACS Audit.7.4.2 Recommendation The NSU should offer differential treatment paymentsto DHB's employing surgeons participating in the RACS Audit.7.5 Availability of Radiation Therapy. Several people I met raised the problemcaused by the shortage of radiotherapy in New Zealand, which means that womenwith breast cancer may have to wait 3 months post-surgery for adjuvant radiotherapyto be started. This was felt to be a particular problem for women with DCIS, forwhom local excision with adjuvant radiotherapy was prescribed, but among whomsome (or their surgeons) were opting for mastectomy in order to ensure that treatmentwas completed promptly. The purpose of adjuvant radiotherapy is to kill off anymalignant or pre-malignant cells that might be occult in the remaining breast tissueafter local excision. At least one trial has shown that local recurrence of breast cancerin patients, treated for DCIS by local excision, is reduced in those who have adjuvantradiotherapy. But there are no data that I know of about the time interval betweensurgery and radiotherapy. Intuitively one may doubt whether many cells with occultmalignant change will progress to invasive cancer within three months. Decisionsabout the optimum treatment for DCIS must await further randomised controlledtrials, and it seems likely that different treatment regimes will be recommended forlesions with different markers of malignancy. In the meantime the shortage of24
adiotherapy remains a problem for women with invasive cancer as well as those within situ disease, but it is outside the remit of this review.7.6 Monitoring the Quality of Treatment. Given the diversity of treatment sites itis not surprising that there has been considerable difficulty in retrieving information.Standard record forms have been drawn up, both for the detailed pathology of theexcised cancer and axillary nodes, and for the type of surgery, radiotherapy, endocrinetherapy and chemotherapy given as part of definitive treatment. But the pathologist,surgeon and oncologist concerned may be unaware he/she is supposed to complete aBSA record for a particular patient among many others. Moreover, even if aware,many pathologists and surgeons are unwilling to complete synoptic forms designedfor computer entry, and prefer to depute this task to other staff to abstract data fromtheir text record. The ease of collaboration between different pathologists is mademore difficult by the intense competition between different private pathologylaboratories.7.6.1 Final Pathology Record . As already seen, one of the early criteria for judgingthe performance of screening is the detection rate of small invasive cancers, and nodenegativecancers. This information is not available from the needle biopsy, and thusthe Screening Centre has to find out the final pathology result, giving the type oftumour (invasive or in situ), size of tumour and nodal status. For breast cancersdiagnosed in screened women up to the end of March 2001, only one Lead Provider,(BSCC), had reached the target set by the Independent Monitoring Group thattreatment data should be available for 90% before the IMG would conduct an analysisby stage. Two LPs, (BSC and BSHC) were particularly behind. In the Lead Providerswhich are doing well, particularly BSCC this is entirely due to the efforts of theBreast Care Nurses who spend a large part of their time visiting a number of differenthospitals and abstracting data from case-notes.The detailed pathology record is increasingly recognised to be an importantdeterminant of adjuvant therapy. In deciding how to treat an individual caseinformation is not only needed about size and nodal status but also nuclear grade,vascular invasion, Estrogen and Progesterone Receptor status, and possibly othermarkers of malignancy in the future. In speaking to pathologists in the six LeadProvider centres, and in observing coding of breast cancer reports in the CancerRegistry, I was impressed at the completeness and organisation of written reports,which all contained the needed information. But there is still an unwillingness toreport on synoptic forms. Although the Breast Care Nurses are doubtless well-trainedand competent to abstract these data, this is not part of their job and should not betheir responsibility. It would be preferable if the Lead Pathologist in each LeadProvider took responsibility for completing the record forms not only for the caseshe/she reports on personally, but also for obtaining completed forms from colleaguesin all hospitals to which women are referred. This would not only have the advantageof placing responsibility for the accuracy of the report on the person who makes thediagnosis, but also would give the Lead Pathologists a greater sense of involvement inBSA as a whole, particularly in terms of the stage at which cancers are detected. I feltthat some, but not all, Lead Pathologists saw their role in BSA as ending after theyhave reported on the biopsy and discussed it at a multidisciplinary meeting.25
Page 1 and 2: BREASTSCREEN AOTEAROAAN INDEPENDENT
Page 3 and 4: I SUMMARYSUMMARY AND RECOMMENDATION
Page 5 and 6: Independent Monitoring Group10. The
Page 7 and 8: patient when she might not otherwis
Page 9 and 10: Waikato area and the Bay of Plenty,
Page 11 and 12: 5. POPULATION COVERAGE5.1 Estimates
Page 13 and 14: 5.3.4 Routine Rescreens. The second
Page 15 and 16: Although the register is held withi
Page 17 and 18: of enabling women to reach the scre
Page 19: testing system set up by the Royal
Page 22 and 23: again all Lead Providers have has m
Page 26 and 27: 7.6.2 Recommendation The Lead Patho
Page 28 and 29: in any case calculated routinely by
Page 30 and 31: BSA. (A minor easily correctable fa
Page 32: 10. INFORMATION SYSTEMS IN BSA10.6.
Page 37 and 38: 14. RELEVANCE OF THE GISBORNE INQUI
Page 39 and 40: a radiologist working in isolation.

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