Breast Cancer Services in Ireland

Transcription

1 Breast Cancer Services in Ireland European Commission Joint Research Centre, Ispra March 14 th 2013 Dr Jerome Coffey MD, FRCPI, FRCR, FFR RCSI Radiation Oncology Advisor on behalf of Dr Susan O Reilly MB, FRCPC, FRCPI National Director, National Cancer Control Programme

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5 The Challenges in Ireland 2013 Growth in incidence and prevalence of cancer. Mediocre survival up to Growth in cancer services. Fiscal constraints and recruitment moratorium. Rapid emergence of effective new diagnostic tests and treatments for cancer all at significant additional costs.

6 Growth in Incidence of Invasive Cancers All invasive 26,283 38,379 54, year growth rate 108%

7 The Opportunities Increasing International and National focus on cancer prevention: education, facilitation and empowerment of society to address tobacco (Public Health Act 2004), alcohol, obesity, diet, exercise and sun exposure. Population screening programmes BreastCheck, CervicalCheck, BowelScreen (2012). Strong Department of Health and Health Service Executive support for the National Cancer Control Programme s new and existing strategies and services.

8 The Opportunities 2 Collaborative initiatives to improve population and patient pathways for diagnosis and care (public health, primary care, acute hospital services). -Building on base of successful implementation of the National Strategy for Cancer Control. -Referral to Designated Cancer Centres (8). -High volume, expert oncologists. -Multidisciplinary review.

9 BreastCheck National Screening Programme Free digital mammogram every 2 years for women aged Women invited either to a mobile or screening unit Aim to detect breast cancer at the earliest possible stage when easier to treat with a higher chance of a good outcome

10 BreastCheck National Screening Programme In 12 years of breast screening, BreastCheck has Screened over 371,200 women aged Provided over 835,500 mammograms. Detected over 5,400 breast cancers. Major expansion Completed national rollout 2011.

11 BreastCheck National Screening Programme In 2011, BreastCheck Invited 172,076 women for a free mammogram 72.2% of women accepted their invitation Screened 125,329 women (4,500 more than 2010) Detected 832 breast cancers Annual Report

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15 Comparison No. hospitals carrying out surgery 2005, 2010, No. hospitals Lung Breast Rectal Prostate Oesophageal Cancer Surgery

16 Symptomatic Breast Clinics Electronic referral from GPs to 8 hospitals. GP Guidelines. Rapid access to diagnosis and treatments. Key Performance Measurements published monthly. Annual Quality, Audit & Safety Conference. Annual Reports

17 Healthlink in conjunction with the NCCP and the GPIT Group e-referrals from accredited GP software systems to the 8 designated cancer centres Breast, Prostate & Lung Referral generated from within the patient file, delivered to the cancer team, response within 5 working days Immediate acknowledgment indicating successful delivery of referral Response from the cancer team integrated with the patient file providing a complete record of the referral/response process.

18 Symptomatic Breast Clinics Attendances * Urgent 12,533 13,759 14,087 Non urgent 25,078 24,196 24,279 All attendances 37,631 37,955 38,336 no. primary cancers 2,012 2,145 2,118 % primary cancers 5.4% 5.7% 5.5%

19 Standard 1. Access 1(a) Urgent attendances seen in < 10 working days Target: > 95% 1(b) Routine attendances seen in <12 weeks Target: > 95% 1(c) Urgent imaging (mammo or ultrasound) if S4/S5 Target: > 90% 1(d) Routine imaging (mammo or ultrasound) <12 weeks Target: > 90%

20 Standard 2. Imaging 2(a) Pre-op assessment. Patients with primary operable breast cancer shall have pre-op mammo and U/S Target: >95% 2(b) Targeted imaging. A patient >35 years with a clinically palpable focal abnormality shall have mammo and targeted U/S Target: >95% 2(c) Core biopsies shall be image-guided if R3, R4 or R5 imaging abnormality identified. Target: >90% 2(d) Every consultant radiologist shall report >1,000 mammos per year

21 Standard 3. Diagnosis 3 (a) Non operative diagnosis Patients with invasive breast cancer shall be diagnosed without an operative procedure [open biopsy]. Target >90% 3(b) Timely discussion For patients urgently triaged by the cancer centre and subsequently diagnosed with a primary breast cancer, the interval between attendance at the first clinic and discussion at the MDM shall not exceed 10 working days.target >90%

22 Standard 4. Multidisciplinary Care 4(a) Breast investigations that generate a histopathology report shall be discussed at MDM. Target >95% 4(b) All patients with a diagnosis of breast cancer from the symptomatic service shall be discussed at MDM. Target >95%

23 Standard 5 Time to treatment 5(a) Surgery 5(a) Surgical intervention shall be carried out within 4 weeks (20 working days) of the MDM when a B5 or C5 is first identified, provided surgery is the first treatment Target: >90%

24 Standard 5 Time to treatment 5(b,c) Time to radiotherapy 5(b) For patients, where adjuvant chemotherapy is not deemed necessary but require radiation therapy, patients shall commence RT within 12 weeks of the final surgical procedure. Target: >90% 5(c) For patients, requiring adjuvant chemotherapy and radiation therapy, patients shall RT within 4 weeks of the last chemotherapy administration. Target: >90%

25 Standard 5 Time to treatment 5(d) Time to chemotherapy 5(d) For patients, where adjuvant chemotherapy is required, administration shall commence within 8 weeks of the final surgical procedure. Target: >90%

26 Standard 6 Surgery Accurate Localisation Patients with a clinically occult lesion, that is classified as an S2, shall have wire-guided localisation pre-operatively. Target: >95% Patients with a clinically occult lesion who have a wire-guided wide local excision shall have specimen mammography. Target: >95%

27 Standard 7 Surgery Axillary Staging Patients with a diagnosis of primary operable invasive breast cancer shall have an ultrasound of the axillary nodes. Target >95% The number of patients with sonographically normal lymph nodes and where the FNA or core biopsy does not demonstrate metastases and who have sentinel lymph node biopsies shall be documented.

28 Standard 8 All consultant surgeons should assess and operate on a minimum of 50 new patients with breast cancer per year.

29 Standard 9 For patients who have breast conserving surgery, 95% or more patients should have three or fewer therapeutic operations.

30 Standard 10: Pathology Pathology reports shall include a standard set of prognostic indicators that will be available to the multidisciplinary team in a timely fashion. For patients with primary invasive breast cancer: Tumour type, grade, size, lymphovascular invasion and posterior margin status were recorded for their highest grade tumour.

31 Standard 10: Pathology ER, HER-2 status is recorded for the highest grade tumour. Axillary lymph node status, where sampled, shall be recorded. Radial margin status shall be documented for all patients who have wide local excision of a primary invasive breast cancer. The histopathology report will be available within 10 working days.

32 National Radiation Oncology Programme St Luke s Radiation Oncology Network now fully developed: 2 new Dublin centres opened in 2011, in addition to St Luke s Hospital. 50% increase in capacity. 100 million approved to build new facilities in Cork and Galway to accommodate increase in demand (opening 2017). National Treatment Guidelines developed and in final review. Cross Border planning with Northern Ireland to address radiotherapy needs for the North West in new Altnagelvin centre (2016).

33 National Medical Oncology and Haemato- Oncology Programmes Evidence-based national guidelines, treatment protocols Quality and safety policies for safe drug delivery NCCP Technology Review Committee for oncology drugs and related molecular tests implemented March National oncology drug budget implemented in 2013.

34 National Cancer Drug Management Oral drugs: PCRS 50% of expenditure. Parenteral drugs: Individual hospitals. Overall spend 150m per annum. Growth rate: 15% per annum in hospitals. New drugs > 45,000/QALY. Patients increase by 5% per annum.

35 National Cancer Drug Management 2 1. Implementation of central funding for high cost drugs 2013 onwards. 2. Protocols / Order Sets / Patient information. 3. Registration by diagnosis. 4. Financial / reimbursement process for new drugs.

36 National Tumour Groups Initiated May 2011: GI, Breast, GU, Lung, Gynaecology Role: Development and promulgation of site-specific, evidence-based multidisciplinary clinical practice guidelines. Adopt / Adapt / Innovate Initial leadership representatives from: Surgical, Medical & Radiation Oncology Pathology & Diagnostic Imaging Related experts e.g. Respirology, Gastroenterology

37 Age standardised survival at 5 years for cancers diagnosed in (all), (Ireland) and (others) Source: Irish data NCRI 2008 & international data Lancet 2010

38 Irish cancer survival can improve by up to 10% by successful implementation of well-organised cancer control systems.

39 Critical Success Factors Population-based screening Early diagnosis / Stage Shift Multidisciplinary Teams High Volume / Expert Centres National Standards / Guidelines / Protocols / Policies / Processes