BREAST CANCER 2010 COMPARATIVE AUDIT REPORT

Transcription

1 SOUTH EAST SCOTLAND CANCER PROSPECTIVE CANCER AUDIT BREAST CANCER 2010 COMPARATIVE AUDIT REPORT Dr Jeremy Thomas, NHS Lothian Chair, Breast Group Miss Fawzia Ashkanani, NHS Dumfries and Galloway Mr Matthew Barber, NHS Lothian Mr Glyn Neades, NHS Fife Mr John O Neill, NHS Borders Christine Dodds Senior Breast Cancer Audit Facilitator Martin Keith, Senior Cancer Information Officer, NHS Dumfries & Galloway Maggie McHardy, Cancer Audit Facilitator, NHS Fife Alistair Meikle, Cancer Audit Facilitator, NHS Borders SA B01 12W Audit Office, c/o Department of Clinical Oncology, Western General Hospital, Crewe Road, Edinburgh EH4 2XU T: W: Alison.Allen@luht.scot.nhs.uk

2 CONTENTS DOCUMENT HISTORY... 4 OVERALL COMMENT BY CHAIR OF BREAST GROUP... 5 ACTION POINTS carried forward from 2010 report... 6 DATA QUALITY Case Ascertainment: Comparison of numbers recorded in Audit and by Scottish Cancer registry 2006, 2007, 2008 (*2009 data has been received from the Scottish Cancer Registry) AGE DISTRIBUTION OVERALL WORKLOAD OF BREAST SERVICES IN OVERALL NEW PATIENT ATTENDANCE AT BREAST SERVICES IN BORDERS RESULTS NHSQIS SECTION 2: SERVICE DELIVERY Standard 5: GP referral to breast clinic a.1 GP referral to symptomatic breast clinic within 28 days a.2 GP referral to symptomatic breast clinic within 14 days Standard 6: Waiting time for diagnosis a. Diagnosis within 14 days of first clinic visit Standard 7: Waiting time for treatment - Surgery a.1 Surgery as first treatment within 31 days of diagnosis a.2 Neoadjuvant or primary chemotherapy within 31 days of diagnosis Standard 7: Waiting time for treatment - primary/neoadjuvant Hormone therapy a.3 Neoadjuvant or primary hormone therapy within 31 days of diagnosis Standard 7: Waiting time for treatment - adjuvant Radiotherapy a.4 Adjuvant radiotherapy within 42 days of final surgery or final chemotherapy Standard 7: Waiting time for treatment - adjuvant Chemotherapy a.5 Adjuvant chemotherapy within 42 days of final therapeutic operation Standard 7: Waiting time for treatment - referral to first treatment a.6 All patients receive first treatment within 62 days of GP referral Standard 8: Diagnosis a. Non operative diagnosis (FNA or core biopsy) Standard 9: Surgical management a. Surgical treatment b. Conservation rate for small tumours c. Immediate breast reconstruction d. Final excision margins <1mm e. Patients with surgically treated invasive tumours receiving axillary surgery f. Patients with small invasive tumours have node sampling or sentinel node biopsy rather than clearance Standard 10: Pathology a.1 Surgically treated invasive breast cancers have the tumour grade reported a.2 Surgically treated breast cancers have the closest margin reported in mm a.3 Whole tumour size reported in mm including invasive and in situ disease b.1 ER status reporting b.2 Her2 status recording Standard 11: Oncological management a. Radiotherapy to breast after conservation for invasive cancer b. Radiotherapy to axilla for positive nodes where completion clearance not performed c. Hormone therapy for ER positive patients with invasive tumours d.1 Patients less than 50 at diagnosis, node positive, receive chemo d.2 Patients less than 70 at diagnosis who are ER/PR negative, node positive, Breast Cancer Audit Report 2010 SA B01 12W 2

3 receive chemotherapy e. Herceptin for HER2 positive patients who have had chemotherapy Standard 12: Clinical trials a. Clinical trial entry Section 4: Outcomes Standard 13: Long-term outcome of treatment SUMMARY BY KEY CATEGORIES WESTERN GENERAL HOSPITAL SUMMARY BY KEY CATEGORIES ST JOHN S HOSPITAL, WEST LOTHIAN Summary by Key Categories Queen Margaret Hospital Summary by Key Categories Borders General Hospital GLOSSARY [Extracts from Standards for Cancer Services (Breast Cancer) NHSQIS 2008] Breast Cancer Audit Report 2010 SA B01 12W 3

4 DOCUMENT HISTORY Version Date Events Deadline Action 1 25/10/ /11/11 18/11/ /03/ /04/ /05/12 Version 1 Breast Comparative 2010 data tables discussed at meeting with Chair Version 2 Breast Comparative 2010 Data incorporated into national slides presented at National Networks Meeting, Dundee Version 3 circulated to Breast Group, final comments invited Version 4 approved by Lead Clinician and signed off. Version 4 circulated to the Health Board Clinical Governance Groups and to the RCPG. Audit staff assess report for risk of disclosing any sensitive personal information. Amendments made as required. D&G data awaited comparative data presented in EBU; consultants representing all 5 hospitals in attendance. National report to be published in due course Version 4 prepared incorporating comments received Consideration by Lead Clinicians of any comments received from Clinical Governance Groups or RCPG. Version 4 W (for website) prepared. 4W June 2012 Version 4W lodged on website Breast Cancer Audit Report 2010 SA B01 12W 4

5 OVERALL COMMENT BY CHAIR OF BREAST GROUP: DR JEREMY THOMAS I am pleased to present the Comparative Audit Report on patients newly-diagnosed with Breast Cancer in health boards in These results were presented at the national breast networks meeting in Dundee in November 2011, where comparison in the wider context gives us considerable confidence that the clinical quality of the service received by patients in health boards matches any in Scotland. Breast Cancer Lead Clinicians in individual health board areas have checked the results at local level, and the collated report has been reviewed by lead clinicians from across the network. This means that we can be very confident in the accuracy of the results shown. We are very grateful for the commitment and hard work of the audit staff especially Christine Dodds, Senior Cancer Audit Facilitator. As indicated in the summary of results at the beginning of the report we uniformly meet 19 of the 29 national standards reported, almost all at the higher desirable level with only a few at the basic essential level. Where we do less well is in the standards relating to timeliness of process. We only meet 2/9 of these. Indeed, results have in some cases worsened. Our Action Points are accordingly aimed at resolving delays in access to surgery, and neoadjuvant and adjuvant chemotherapy, and adjuvant radiotherapy. One other standard which we take very seriously and which is less well met than we would like, relates to percentage entry into trials, which varies significantly between boards. In part this may be due to the current reporting by year of diagnosis, and the need to change to report by year of recruitment. Prospective audit data provided the basis for survival analysis by ISD in 2009, and it was not thought necessary to repeat this as soon as results showed, for All Breast Cancer Patients, Relative Survival (i.e. calculating the probability of survival from cancer in the absence of other causes of death) as 97.8% at 1 year and 87.7% at 5 years. These results are broadly in line with results elsewhere in Scotland. This year we have taken part in the development of Scottish national Quality Performance Indicators (QPIs) for Breast Cancer and we look forward to the implementation and reporting of these. Other topics that we would like to review further include the management of the axilla in patients with positive sentinel nodes an area of active debate. We need to keep our sights focussed on a continuous quest for improvement in patient care and outcome. Jeremy Thomas Chair, Breast Group March 2012 Breast Cancer Audit Report 2010 SA B01 12W 5

6 ACTION POINTS carried forward from 2010 report Report Section Possible area for improvement Proposed action Standard % patients recruited to Re-evaluation of clinical trials 12a.1 clinical trials to be increased. recruitment. Clinical Trials Matrix to be made available to the MDT to assist with the identification of patients for available trials. Progress made to date Trials personnel have been asked to provide a summary document to aid the identification of potential trials for individual patients, as they are discussed. 8/11/11: agreement that it is more appropriate to report by year of randomisation, with a summary report being provided by SCRN (Scottish Cancer Research Network) and trials nurses. SCRN to be approached with a view to revised reporting in ACTION POINTS 2011 Report Possible area for Section improvement 6a - STJ Access to ultrasound: Patients diagnosed at St. John s Hospital do not benefit from one-stop ultrasound facility. This leads to unsatisfactory MDM discussions of these patients and may amount to inequality of service provision for St. John s patients 7a.1 - WGH Time to surgery as first treatment: Time taken at WGH has worsened since the 2009 report Proposed action This problem has previously been highlighted but funding has not yet been made available. Clinicians at WGH are aware of the delay and have established that it is not due to theatre availability. The large proportion of Screeners, and the improved imaging now available, has resulted in an increase in the number of pre-operative investigations being undertaken, which impacts on time to surgery. This issue will be kept under review. Which clinical standard will this meet? 6a. This standard is currently met. 7a.1 Breast Cancer Audit Report 2010 SA B01 12W 6

7 7a.2 - WGH Time to neoadjuvant chemotherapy 7a.4 - WGH Time to adjuvant radiotherapy Medical oncologist (Dr Hayward) will investigate the possibility of flagging up this target date to Ward 1 staff when patients are referred for neoadjuvant chemotherapy. The booking process for adjuvant radiotherapy will continue to be closely monitored in an attempt to re-gain the ground that was achieved during the previous year. Medical oncologists will draw the attention 7a.5 - WGH Time to adjuvant chemotherapy of management to the capacity issues. 12a Clinical trial entry This remains a problem area for breast services in S E Scotland, having been an action point in the 2009 annual report. In future, SCRN will be invited to provide information on patients being recruited to clinical trials, by year of recruitment to the trial, rather than year of diagnosis. 7a.2 7a.4 7a.5 12a Breast Cancer Audit Report 2010 SA B01 12W 7

8 SUMMARY OF RESULTS Key D E N Desirable standard met (% achieved) Essential standard met (% achieved) Essential standard not met (% achieved) Note: number beside N indicates % achieved Standard Description WGH St Johns QMH BGH D&G 5a.1 5a.2 6a.1 7a.1 7a.2 7a.3 7a.4 7a.5 7a.6 8a.1 9a.1 9b.1 9c.1 9d.1 9e.1 9f.1 GP referral to symptomatic breast clinic within 28 days Essential: 80% Desirable: 95% E 94 E 93.4 E 90.4 E 92 D GP referral to symptomatic breast clinic within 14 days Desirable: 80% NB: This is not an Essential standard N 11.6 N 40.8 N 58.9 N 61 D Diagnosis within 14 days of first clinic visit D E 93.4 D D D Essential: 80% Desirable: 95% Surgery as first treatment within 31 days of diagnosis Essential: 80% Desirable: 95% N 68.4 E 90.5 N 56 E 94 D Primary or neoadjuvant chemotherapy within 31 days of diagnosis. Essential: 80% Desirable: 95% Primary or neoadjuvant hormonal therapy within 31 days of diagnosis. Essential: 80% Desirable: 95% Radiotherapy (adjuvant) within 42 days of final therapeutic operation/chemotherapy dose. Essential: 70% Desirable: 85% Chemotherapy (adjuvant) within 42 days of final therapeutic operation. Essential: 80% Desirable: 95% First treatment within 62 days of GP referral (all GP referrals urgent and non urgent) Essential: 80% Desirable: 95% N 71.4 D N 67.7 N 67 E 87.5 D D D E 93 D N 63.9 E 73.2 E 71.8 D 93 E 75 N 72 E 85 N 69 E 88 E 82 E 89 E 94.7 E 86.3 D D Non operative diagnosis (FNA or core biopsy) D D D D D Essential: 85% Desirable: 95% Surgical treatment Essential: 70% Desirable: 80% D D D D D Conservation rate for small tumours Essential: 75% Desirable: 85% D D D D D Immediate breast reconstruction Essential: 5% minimum Desirable: 10% min. D D D D D Final excision margins <1mm D D D D D Essential: 10% max Desirable: 5% max. Axillary surgery for surgically treated invasive tumours Essential: 90% Desirable: 95% Small invasive tumours have node sampling or sentinel node biopsy rather than clearance Essential: 75% Desirable: 85% D D D D D D D D D D Breast Cancer Audit Report 2010 SA B01 12W 8

9 Standard Description (continued) WGH St Johns QMH BGH D&G Minimum of four nodes removed 9g.1 Essential: 10% max Desirable: 5% max D D D D D 10a.1 10a.2 10a.3 10b.1 10b.2 11a.1 11b.1 11c.1 11d.1 11d.2 11e.1 12a.1 Surgically treated invasive breast cancers have the tumour grade known and reported. Essential: 90% Desirable 95% D D D D D Closest margin reported in mm D D D D D Essential: 90% Desirable 95% Whole tumour size reported in mm D D D D D Essential: 90% Desirable 95% ER status reporting D D D D D Essential: 90% Desirable 95% Her2 status recording Essential: 90% Desirable 95% D D D D E 92.3 Radiotherapy to breast after conservation for invasive cancer Essential: 85% Desirable 95% Radiotherapy to axilla for positive nodes where completion clearance not performed Essential: 85% Desirable 95% Hormone therapy for ER positive patients with invasive tumours Essential: 90% Desirable 95% Patients less than 50 at diagnosis, node positive, receive chemo Essential: 85% Desirable 95% Patients less than 70 at diagnosis who are ER/PR negative, node positive, receive chemotherapy Essential: 80% Desirable 90% Herceptin for HER2 positive patients who have had chemotherapy Essential: 70% Desirable 80% E 91.5 D D D E 94.3 D D D D D D D D E 90.6 D E 94.6 E 90 D D D D E 85.7 D D D D D E 77 D D Clinical trial entry E 5.1 N 3.7 N 1.1 N D Essential: 5% minimum Desirable 10% Breast Cancer Audit Report 2010 SA B01 12W 9

10 INTRODUCTION AND METHODS Cohort This report presents analysis of data collected on female breast cancer patients diagnosed between 1 January and 31 December 2010 in the four health board regions comprising S E Scotland Cancer Network () Borders, Dumfries & Galloway, Fife, and Lothian. Dataset and Definitions The dataset collected is the SIGN Core Minimum dataset as published by SCTN in August 1999, and revised in June Further information on the dataset and definitions can be obtained from Christine Dodds, Senior Audit Facilitator, Audit Office, c/o Dept of Clinical Oncology, Western General Hospital, Edinburgh. (Christine.dodds@luht.scot.nhs.uk). Audit Process Patients were mainly identified through registration at weekly multidisciplinary meetings. Data capture was dependent on either a casenote audit, or review of various hospitals electronic records systems. During 2010, electronic sources were noted to have developed sufficiently to become the primary data source for the majority of the breast cancer audit data items. Data was recorded on CIM (Clinical Information Management System) in Lothian and Dumfries and Galloway, and on an Access database in Borders. During 2010, Queen Margaret hospital, Fife opted into Ecase, a web-based audit database. In view of the cut-off point for reporting these results in November 2011, some patients diagnosed in 2010 (especially those whose initial treatment was hormone therapy) had not completed primary treatment and as a result there are a small number of gaps in the data. Lead Clinicians and Audit Personnel Hospital/Network Lead clinician Audit Support Borders General Hospital (BGH) Mr John O Neill (JON) Alistair Meikle Dumfries & Galloway Royal Infirmary (D&G) Miss Fawzia Ashkanani (FA) Martin Keith Edinburgh Breast Unit, Mr Matthew Barber (MB) Christine Dodds Western General Hospital, Lothian (WGH) Queen Margaret Hospital, Fife (QMH) Mr Glyn Neades (GTN) Maggie McHardy St John s Hospital at Howden, West Lothian Mr Matthew Barber (MB) Christine Dodds (STJ) Dr Jeremy Thomas (JT) Christine Dodds Basis of Analysis Measures presented are based on nationally-agreed standards for breast cancer care, published by NHS Quality Improvement Scotland (NHS QIS) in March 2008 ( Reporting of Results Results of analysis were presented at a meeting of the three Scottish Breast Cancer networks held in Dundee on 18 November Breast Cancer Audit Report 2010 SA B01 12W 10

11 Actions for Improvement After final sign off of this document, the process is for the report to be sent to the Clinical Governance groups within the four health boards and to the Regional Cancer Planning Group. Action plans and progress with plans will be highlighted to these groups. The report has been placed on the website after checks and editing of any disclosive material. Action points for 2010 audit results: as part of clinical sign-off areas for improvement are highlighted in the Action Points above. Action points from 2009 results: information is provided on progress with Action Points for Breast Cancer Audit Report 2010 SA B01 12W 11

12 DATA QUALITY External Quality Assurance (QA): All hospitals in the region participate in the Quality Assurance programme provided by the National Services Scotland Information Services Division (ISD). Previous quality assurance examination of data against national data definitions showed accuracy rates >90%. Case Ascertainment: Patients are mainly identified for audit through registration at weekly Multidisciplinary Team meetings (MDMs). Coverage of the population of breast cancer patients are assessed in comparison with Cancer Registration data (see Table in Numbers in Audit below). High percentages of case ascertainment provide confidence that results are based on complete capture of all patients diagnosed in the cohort reported. Case Ascertainment: Comparison of numbers recorded in Audit and by Scottish Cancer registry 2006, 2007, 2008 (*2009 data has been received from the Scottish Cancer Registry) 2006 Cancer Registrations by Hosp Diagnosis Breast Audit 2006 % 2006 Cancer Registrations Total % Source: Scottish Cancer Registry 2007 Cancer Registrations by Hosp Diagnosis Breast Audit 2007 % 2007 Cancer Registrations Total % Source: Scottish Cancer Registry 2008 Cancer Registrations by Hosp Diagnosis Breast Audit 2008 % 2008 Cancer Registrations Total % Source: Scottish Cancer Registry (females and males included) * have requested a cross match of 2009 Lothian patient identifiers from the Cancer Registry in order to check the validity of the Cancer Registry total for 2009, which is higher than expected. Overall case ascertainment across the network of between 96.6% and 97.8% over the preceding 3 years provides confidence in the quality of the results. Comparing the 2010 total (1152) with the average Cancer Registration total over the 3 years shown above (1185), case ascertainment for 2010 is estimated to be 97.2%. Higher numbers of patients in recent years may have been due to the expansion of the Breast Screening Service which has now peaked and fewer new patients are being diagnosed. This can be reviewed when 2009 Cancer Registration data has been checked against data. Numbers in Audit Females diagnosed during 2010 Males diagnosed during 2010 WGH STJ QMH BGH 59 0 D&G Total Breast Cancer Audit Report 2010 SA B01 12W 12

13 Whilst only female patients are reported on here, data is collected on all male patients diagnosed with breast cancer, numbers as shown above. Male patients will be reported on separately at a later date. AGE DISTRIBUTION Age of patients at diagnosis Age of patient WGH STJ QMH BGH D&G < % 0 0% 1 0.5% 0 0.0% 1 0.9% % 3 2.8% % 3 5.1% 4 3.6% % % % % % % % % % % % % % % % % % % % % % % % % % Total Median Variation in the age distribution of patients in different parts of the region may need to be considered where apparent discrepancies are found in percentage of patients receiving specific forms of treatment. It is particularly significant to note that in BGH, almost 50% of patients are aged 70 or over. Age of the patient can be a factor in the take-up of oncology treatment, as this may involve significant travel to access centralised services, particularly radiotherapy which is available in Edinburgh, Glasgow or Carlisle. Clinical Sign-Off: This report compares data from reports prepared for individual hospitals and signed off as accurate following review by the lead clinicians from each service. Additionally, the collated results are reviewed by lead clinicians, including lead Oncologists, to assess variances and provide comments on results. Breast Cancer Audit Report 2010 SA B01 12W 13

14 OVERALL WORKLOAD OF BREAST SERVICES IN Numbers of patients diagnosed should be viewed within the context of the overall work of the Breast Services. E.g. the overall number of new patients seen within Lothian between 2007 and 2010 are shown below. The majority of new patients are diagnosed with benign breast conditions. It is clear that the number of new patients being referred for assessment is continuing to rise and there is an inevitable pressure on services as a result. BREAST SURGERY NEW PATIENT ATTENDANCE ACTIVITY 2007 Location Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total WGH STJ Total Location Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total WGH STJ Total Location Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total WGH STJ Total Location Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total WGH STJ Total Data source: Performance Management department, NHS Lothian It is hoped in future reports to show similar information from other health board areas. OVERALL NEW PATIENT ATTENDANCE AT BREAST SERVICES IN BORDERS BGH Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total Breast Cancer Audit Report 2010 SA B01 12W 14

15 RESULTS NHSQIS SECTION 2: SERVICE DELIVERY Standard 5: GP referral to breast clinic with GPs to achieve Standard Statement 5a: Breast units collaborate with GPs to achieve appropriate and rapid referral of patients suspected of having breast cancer Essential Criterion 5a.1 A minimum of 80% of patients referred to a symptomatic breast clinic, who are diagnosed with breast cancer are seen within 28 days from the date of GP referral. Numerator: All patients diagnosed with breast cancer referred by their GP to a symptomatic breast clinic who are seen within 28 days from date of GP referral. Denominator: All patients diagnosed with breast cancer, referred to a symptomatic clinic by a GP Exclusions: All patients referred by a source other than their GP. All patients with an incidental diagnosis at follow-up (i.e. previous cancer or family history) Desirable Criterion 5a.2 80% of patients with breast cancer referred to a symptomatic breast clinic are seen within 14 days from the date of GP referral. 5a.3 A minimum of 95% of patients referred to a symptomatic breast clinic, diagnosed with breast cancer, are seen within 28 days from the date of GP referral. All results: Date of Diagnosis in range 01/01/10 31/12/10 5a.1 GP referral to symptomatic breast clinic within 28 days NHS QIS Essential: 80% Desirable: 95% Numerator Null or not rec Target not met Denominator Range Median a.2 GP referral to symptomatic breast clinic within 14 days Desirable standard: 80% * Note: this is not an essential standard * Numerator Null or not recorded Target not met Denominator Breast Cancer Audit Report 2010 SA B01 12W 15

16 Comment: This desirable standard remains extremely challenging with D&G alone achieving it. Standard 6: Waiting time for diagnosis Standard Statement 6a: Where a localised abnormality is present, the time between triple assessment to accurate diagnosis is minimised. Essential Criterion 6a.1 A minimum of 85% of breast cancer patients have a diagnosis within 14 days of first clinic visit (including image-guided needle biopsy). Numerator: All breast cancer patients receiving a diagnosis within 14 days of first clinic visit. Denominator: All patients referred directly to a symptomatic breast clinic by a GP, who are diagnosed with breast cancer. Exclusions: All patients referred by a source other than their GP. All patients with incidental diagnosis at follow-up (previous cancer or family history) Desirable Criterion 6a.2 A minimum of 95% of breast cancer patients have a diagnosis within 14 days of first clinic visit (including image-guided needle biopsy). 6a. Diagnosis within 14 days of first clinic visit NHS QIS Essential: 85% Desirable: 95% Numerator Null or not recorded Target not met Denominator Range Median Comment: The breast service at St Johns is still awaiting a one-stop ultrasound facility. It is hoped that this will be introduced during Until this becomes available, patients will continue to have core biopsies taken before they have had full imaging of the breast. This is far from satisfactory and it impacts on the availability of all results at the MDM where key decisions are made on treatment. Breast Cancer Audit Report 2010 SA B01 12W 16

17 Standard 7: Waiting time for treatment - Surgery Standard Statement 7a: Waiting times for treatment are within acceptable limits Essential Criterion 7a.1 A minimum of 80% of breast cancer patients who require surgery as their first treatment, undergo surgery within 31 days of diagnosis. Numerator: All breast cancer patients having surgery as 1 st treatment within 31 days of diagnosis Denominator: All breast cancer patients having surgery as their first treatment. Exclusions: Patients diagnosed only at terminal stage of disease for whom no active treatment is felt to be appropriate. Patients who are diagnosed by open biopsy/excision biopsy only. Desirable Criterion 7a.7 A minimum of 95% of breast cancer patients who require surgery as first treatment, undergo surgery within 31 days of diagnosis. 7a.1 Surgery as first treatment within 31 days of diagnosis NHS QIS Essential: 80% Desirable: 95% Numerator Null or not recorded Target not met Denominator Range Median Excludes open biopsies Comment: During 2010, the Scottish Government revised cancer waiting times targets. The new target stipulates that all patients diagnosed with cancer should commence treatment 31 days from the date of decision to treat. The National Breast Cancer dataset does not incorporate a field for date of decision to treat ; therefore it is not possible to provide this result in this report. It should be noted that this pre-existing standard, the results of which are shown here, is measured from date of diagnosis which is earlier in the patient pathway than date of decision to treat. In Lothian it is argued that the increasing delay between diagnosis and surgery is due to an increase in the quantity and complexity of pre-operative investigations. The improved quality of mammography in recent times has meant that smaller lesions are detected, particularly through the Breast Screening Program, and these all require full investigation to clarify their exact nature, to ensure no cancers are missed. This also leads to many patients being discussed on more than one occasion at the MDM, and inevitably this adds to the time taken to reach surgery. Edinburgh Breast Unit is best equipped to investigate and treat the more complex cases, which is reflected in the percentage shown. There was no problem with theatre capacity during this time period. There is an Action Point to review this further. QMH: 28/40 patients (51+28=79 total) had surgery within a further week (i.e. within 38 days = 86.8%) Breast Cancer Audit Report 2010 SA B01 12W 17

18 Standard 7: Waiting time for treatment - neoadjuvant Chemotherapy Standard Statement 7a: Waiting times for treatment are within acceptable limits. Essential Criterion 7a.2 A minimum of 80% of breast cancer patients start primary or neoadjuvant chemotherapy within 31 days of diagnosis. Numerator: All breast cancer patients starting primary or neoadjuvant chemotherapy within 31 days of diagnosis. Denominator: All breast cancer patients receiving primary or neoadjuvant chemotherapy. Exclusions: Patients diagnosed only at terminal stage of disease for whom no active treatment is felt to be appropriate. Desirable Criterion 7a.8 A minimum of 95% of breast cancer patients start neoadjuvant chemotherapy within 31 days of diagnosis. 7a.2 Neoadjuvant or primary chemotherapy within 31 days of diagnosis NHS QIS Essential: 80% Desirable: 95% Numerator Null or not recorded Target not met Denominator Range Median Comment: During 2010, the Scottish Government revised cancer waiting times targets. The new target stipulates that all patients diagnosed with cancer should commence treatment 31 days from the date of decision to treat. The National Breast Cancer dataset does not incorporate a field for date of decision to treat, therefore it is not possible to provide this result in this report. Having the SG target and this QIS standard in place at the same time has caused confusion for staff. As a result, there is a lack of clarity over what the target date should actually be. Breast Cancer Audit Report 2010 SA B01 12W 18

19 Standard 7: Waiting time for treatment - primary/neoadjuvant Hormone therapy Essential Criterion 7a.3 A minimum of 80% of breast cancer patients start primary or neoadjuvant hormonal therapy within 31 days of diagnosis. Numerator: All breast cancer patients starting primary or neoadjuvant hormonal therapy within 31 days of diagnosis Denominator: All breast cancer patients receiving primary or neoadjuvant hormonal therapy. Exclusions: Patients diagnosed only at terminal stage of disease for whom no active treatment is felt to be appropriate. Desirable Criterion 7a.9 A minimum of 95% of breast cancer patients start primary or neoadjuvant hormonal therapy within 31 days of diagnosis. 7a.3 Neoadjuvant or primary hormone therapy within 31 days of diagnosis NHS QIS Essential: 80% Desirable: 95% Numerator Null or not recorded Target not met Denominator Range Median Comment: During 2010, the Scottish Government revised cancer waiting times targets. The new target stipulates that patients referred urgently with suspicion of cancer should commence treatment 31 days from the date of decision to treat. The National Breast Cancer dataset does not incorporate a field for date of decision to treat; therefore it is not possible to provide this result in this report. Breast Cancer Audit Report 2010 SA B01 12W 19

20 Standard 7: Waiting time for treatment - adjuvant Radiotherapy Essential Criterion 7a.4 A minimum of 70% of breast cancer patients start radiotherapy (adjuvant) within 42 days of final therapeutic operation/chemotherapy dose (where radiotherapy follows final chemo cycle) Numerator: All breast cancer patients starting adjuvant radiotherapy within 42 days of final therapeutic operation/chemotherapy dose. This refers to treatment plan at the time of diagnosis and treatment of primary breast cancer and not to the management of later disease progression/recurrence. Denominator: All breast cancer patients receiving adjuvant treatment in the form of radiotherapy. Exclusions: All breast cancer patients receiving radiotherapy, which is given during the course of chemotherapy. Desirable Criterion 7a.10 A minimum of 85% breast cancer patients start radiotherapy (adjuvant) within 42 days of final therapeutic operation/chemotherapy dose 7a.4 Adjuvant radiotherapy within 42 days of final surgery or final chemotherapy NHS QIS Essential: 70% Desirable: 85% Numerator Null or not recorded Target not met Denominator Range Median Comment: A small proportion of patients were still pending treatment at the report cut-off date, and their data is null at the time of reporting. This continues to be a challenging standard to achieve but there is an Action Point to keep performance under review. WGH: WGH differs from the other hospitals in that it treats many Screening patients from Forth Valley who are subsequently referred to the Beatson for radiotherapy. This process takes longer than being treated in ECC, and this is reflected in these results. It is also more difficult to collect the required audit information for these patients, hence the not recorded data. Excluding patients treated at the Beatson (39), and Ninewells (1), WGH would achieve 310/448 (69.2%), with 1 not recorded. Breast Cancer Audit Report 2010 SA B01 12W 20

21 Standard 7: Waiting time for treatment - adjuvant Chemotherapy Essential Criterion 7a.5 A minimum of 80% of breast cancer patients start chemotherapy (adjuvant) within 42 days of final therapeutic operation. Numerator: All breast cancer patients starting adjuvant chemotherapy within 42 days of final therapeutic operation. This refers to treatment plan at the time of diagnosis and not to the management of later disease progression. Denominator: All breast cancer patients receiving adjuvant treatment in the form of chemotherapy. Exclusions: None Desirable Criterion 7a.11 A minimum of 95% of breast cancer patients start chemotherapy (adjuvant) within 42 days of final therapeutic operation 7a.5 Adjuvant chemotherapy within 42 days of final therapeutic operation. NHS QIS Essential: 80% Desirable: 95% Numerator Null or not recorded Target not met Denominator Range Median Comment: Capacity in Ward 1 at WGH is known to be under pressure and this is under review. QMH: 5/9 patients (20+5=25 total) had chemotherapy within a further week (i.e. within 49 days = 86.2%) Breast Cancer Audit Report 2010 SA B01 12W 21

22 Standard 7: Waiting time for treatment - referral to first treatment 62 day target Referral to Treatment - All Patients Essential Criterion 7a.6 A minimum of 80% of all breast cancer patients receive first treatment within 62 days of GP referral. Numerator: All breast cancer patients receiving first treatment within 62 days of GP referral. Denominator: All breast cancer patients referred by their GP (or GP referral direct to A&E), receiving first treatment. Exclusions: All patients diagnosed only at terminal stage of disease for whom no active treatment is felt to be appropriate (or refused all treatment or died before treatment) Desirable Criterion 7a.12 A minimum of 95% breast cancer patients receive first treatment within 62 days of GP referral. 7a.6 All patients receive first treatment within 62 days of GP referral. NHS QIS Essential: 80% Desirable: 95% Numerator Null or not recorded Target not met Denominator Range Median Comment: This standard includes all patients diagnosed with cancer who were referred by their GP and therefore cannot be directly compared with the Scottish Government 62 day target results which is restricted to patients referred urgently with suspicion of cancer. All variances have been examined. Breast Cancer Audit Report 2010 SA B01 12W 22

23 Standard 8: Diagnosis Standard Statement 8a: All efforts are made to diagnose patients non-operatively, allowing them to have only one definitive procedure, where possible. Essential Criteria 8a.1 A minimum of 85% of breast cancer patients have a non-operative diagnosis (FNA/core biopsy/large volume biopsy). Numerator: All breast cancer patients with a non-operative diagnosis of breast cancer (FNA/core biopsy/large volume biopsy). Denominator: All breast cancer patients. Exclusions: Lobular carcinoma in situ (LCIS) Desirable Criterion 8a.3 A minimum of 95% of breast cancer patients have a non-operative diagnosis (FNA/core biopsy/large volume biopsy). 8a. Non operative diagnosis (FNA or core biopsy) NHS QIS Essential: 85% Desirable: 95% Numerator Null or not recorded Target not met Denominator Comment: WGH: all variances have been examined and acceptable reasons were found. 13/21 were cases of DCIS, most of which were incidental findings at surgery eg microdochectomy or mammoplasty. Breast Cancer Audit Report 2010 SA B01 12W 23

24 SECTION 3: CLINICAL MANAGEMENT Standard 9: Surgical management Standard Statement 9a: All patients who do not have metastatic disease are considered for surgery (+/-neoadjuvant treatment). Essential Criterion 9a.1 A minimum of 70% of all breast cancers are surgically treated. Numerator: All breast cancer patients (including neoadjuvant) receiving surgical treatment within 1 year of diagnosis. Denominator: All breast cancer patients. Exclusions: All screen-detected patients. All breast cancer patients found to have metastatic disease during initial investigations. Desirable Criterion 9a.2 A minimum of 80% of all breast cancers are surgically treated. 9a. Surgical treatment NHS QIS Essential: 70% Desirable: 80% Numerator Null or not recorded Target not met Denominator Comment: All variances have been examined. In many cases patients declined surgery or were unfit due to significant co morbidities. Breast Cancer Audit Report 2010 SA B01 12W 24

25 Standard 9: Surgical Management Standard 9b: Breast conservation is appropriate for small focal breast tumours. Essential Criterion 9b.1 There is a minimum of 75% conservation rate of surgically-treated small cancers less than 15mm whole tumour size (pathological diameter/invasive and in situ disease). Numerator: All breast cancer patients with tumour less than 15mm whole tumour size (invasive and in situ disease) treated with breast conservation surgery. Denominator: All surgically treated cancers less than 15mm whole tumour size (pathological diameter/invasive and in situ disease). Exclusions: All breast cancer patients with multifocal disease. All breast cancer patients who have undergone neoadjuvant treatment (either hormonal or chemotherapy). Desirable Criterion 9b.2 There is a minimum of 85% conservation rate of surgically treated small cancers less than 15mm whole tumour size (pathological diameter/invasive and in situ disease). 9b. Conservation rate for small tumours NHS QIS Essential: 75% Desirable: 85% Numerator Null or not recorded Target not met Denominator Comment: All variances have been examined. Breast Cancer Audit Report 2010 SA B01 12W 25

26 Standard 9: Surgical Management Standard Statement 9c Mastectomy patients have access to immediate breast reconstruction. Essential Criterion 9c.1 A minimum of 5% of mastectomy patients have immediate breast reconstruction. Numerator: Patients who underwent immediate breast reconstruction at time of mastectomy. Denominator: All breast cancer patients who underwent mastectomy. Exclusions: None. Desirable Criterion 9c.2 A minimum of 10% of mastectomy patients have immediate breast reconstruction. 9c. Immediate breast reconstruction NHS QIS Essential: 5% minimum Desirable: 10% minimum Numerator Null or not recorded Target not met Denominator Comment: The purpose of this target is to indicate that immediate breast reconstruction is available to patients, should they want it. All hospitals in the region offer immediate breast reconstruction where appropriate. Breast Cancer Audit Report 2010 SA B01 12W 26

27 Standard 9: Surgical Management Standard Statement 9d: Tumours are adequately excised. Essential Criterion 9d.1 A maximum of 10% of breast cancer patients with breast conservation have final excision margins of less than 1mm. Numerator: Patients undergoing breast conservation with final excision margins of less than 1mm (pathological distance). Denominator: All breast cancer patients having breast conservation surgery (invasive tumours or DCIS). Exclusions: LCIS only. Where the only margin <1mm is to an area of LCIS Desirable Criterion 9d.2 A maximum of 5% of breast cancer patients with breast conservation have final excision margins of less than 1mm. 9d. Final excision margins <1mm NHS QIS Essential: 10% maximum Desirable: 5% maximum In line with agreement between the three Scottish Breast Cancer Networks, presentation of this standard is as follows: Cases where only posterior or anterior margins (which would be regarded as clinically acceptable) are <1mm are regarded as meeting the target. Only cases with radial margins <1mm are considered to have missed the target. Numerator Null or not recorded Adequate margins Denominator Comment: All variances have been examined. Breast Cancer Audit Report 2010 SA B01 12W 27

28 Standard 9: Surgical Management Standard Statement 9e: Surgical staging of the axilla is performed in all newly diagnosed patients with operable invasive breast cancer Essential Criterion 9e.1 A minimum of 90% of breast cancer patients having surgery for invasive tumours, undergo surgical staging of the axilla. Numerator: All breast cancer patients with invasive tumours receiving surgical staging of the axilla. Denominator: All breast cancer patients with invasive tumours, having surgery. Exclusions: None. Desirable Criterion 9e.2 A minimum of 95% of breast cancer patients having surgery for invasive tumours, undergo surgical staging of the axilla. 9e. Patients with surgically treated invasive tumours receiving axillary surgery NHS QIS Essential: 90% Desirable: 95% Numerator Null or not recorded Target not met Denominator Comment All variances have been examined. Breast Cancer Audit Report 2010 SA B01 12W 28

29 Standard 9: Surgical Management Standard Statement 9f: To minimise arm morbidity, the extent of surgical staging of the axilla is minimised in patients with a low likelihood of nodal spread. Essential Criterion 9f.1 A minimum of 75% of breast cancer patients undergoing axillary surgery for invasive tumours less than 15mm (invasive pathological diameter) have node sampling or a sentinel lymph node biopsy (SLNB) rather than axillary clearance. (Excluding patients who have undergone neoadjuvant treatment). Numerator: All breast cancer patients undergoing axillary sampling or SLNB for an invasive tumour less than 15mm (invasive component). (Includes patients requiring a subsequent clearance for positive nodes found at the 1 st procedure) Denominator: All breast cancer patients undergoing axillary surgery for invasive tumours less than 15mm (invasive component). Exclusions: All breast cancer patients with pre-operative diagnosis (FNA or core biopsy) of nodal involvement. Patients who have undergone neoadjuvant treatment. Desirable Criterion 9f.2 A minimum of 85% of breast cancer patients undergoing axillary surgery for invasive tumours less than 15mm (invasive component) have node sampling or a sentinel node biopsy rather than clearance. 9f. Patients with small invasive tumours have node sampling or sentinel node biopsy rather than clearance NHS QIS Essential: 75% Desirable: 85% Numerator Null or not recorded Target not met Denominator Comment: At WGH, 6 patients had a clearance which was preceded by an earlier axillary sample or SNB which was found to contain positive nodes or micrometastases. A clearance is acceptable in these circumstances. Breast Cancer Audit Report 2010 SA B01 12W 29

30 Standard 9: Surgical Management Standard Statement 9g: In an axillary sample (excluding dual dye SLNB technique) a minimum of four nodes are removed to predict the pathological node status. This also applies in the case of failed SLNB (failure of any axillary nodes to take up either radioactive colloid or blue dye). Nb Cannot distinguish between guided or unguided procedures with 2010 dataset. Essential Criteria 9g.1 A maximum of 10% of breast cancer patients undergoing unguided surgical staging or blue dye only guided sampling of the axilla have less than 4 lymph nodes removed. Numerator: All breast cancer patients with invasive tumours undergoing surgical axillary staging with fewer than 4 lymph nodes removed. Ie. Number having <4 nodes examined where this is not described as a sentinel node biopsy Denominator: All breast cancer patients with invasive tumours undergoing surgical axillary staging, including axillary node clearance, sampling or failed SLNB. Ie All patients, invasive disease, having surgery to the axilla (excl SNLBs) Exclusions: All breast cancer patients with a successful SLNB. Desirable Criterion 9g.2 A maximum of 5% of breast cancer patients undergoing unguided surgical staging or blue dye only guided sampling of the axilla have less then 4 lymph nodes removed. Numerator Null or not recorded Denominator Comment: Where a sentinel node biopsy is performed, the axillary nodes are very precisely targeted, and therefore fewer require to be removed. The national dataset does not define sentinel node biopsy clearly enough for us to be sure that both blue dye and radioactive isotope were used. For a true sentinel node biopsy, both are required. However, for the purpose of measuring this standard, we have used the data collected, and assumed that where the term is used, it was a true sentinel node biopsy. In WGH and STJ, the variances have been examined and are considered clinically acceptable. QMH: Radioactive isotope is not used at QMH but there were zero patients having <4nodes examined, regardless of how their axillary surgery was described. D&G: no radioactive isotopes used Breast Cancer Audit Report 2010 SA B01 12W 30

31 Standard 9: Surgical Management Standard Statement 9h: In a SLNB using blue dye and radioactive colloid (after the start up phase) the failed localisation rate is kept to a minimum. Nb: Cannot measure this with current dataset Essential Criterion 9h.1 A maximum of 10% of breast cancer patients have a failed SLNB localisation. Numerator: All breast cancer patients with invasive tumours undergoing surgical axillary node staging using blue dye and radioactive colloid in whom the sentinel nodes cannot be identified. Denominator: All breast cancer patients with invasive tumours undergoing surgical axillary node staging using blue dye and radioactive colloid. Exclusions: Patients not undergoing SLNB staging of the axilla. Desirable Criterion 9h.2 A maximum of 5% of breast cancer patients undergoing SLNB have a failed SLNB localisation. Section 3: Clinical management Standard 10: Pathology Standard Statement 10a: Pathology reports of surgically treated breast cancers include the minimum details recommended by SIGN and the NHSBSP. Essential Criteria (Tumour grade) 10a.1 A minimum of 90% of surgically treated invasive breast cancers have the tumour grade known and reported. Numerator: Percentage of invasive breast cancer specimens with the tumour grade reported. Denominator: All breast cancer patients with invasive tumours who undergo definitive surgery. Exclusions: None. Desirable Criterion 10a.4 A minimum of 95% of surgically treated invasive breast cancers have the tumour grade known and reported. 10a.1 Surgically treated invasive breast cancers have the tumour grade reported. NHS QIS Essential: 90% Desirable 95% Numerator Null or not recorded Target not met Denominator Breast Cancer Audit Report 2010 SA B01 12W 31