Why do we need Breast Clinics?

1. Why do we need Breast Clinics? Prof.Dr.M-R. Christiaens Multidisciplinair Borstcentrum

2. 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!!!!

3. The ‘Quality Concept’ • “I recognise it when I see it” • What constitutes ‘quality’? • How can we measure ‘quality’? • How can we improve ‘quality’?

4. Eusoma Guidelines • The Requirements of a Specialist Breast Unit, 2002 • Quality assurance in the diagnosisof 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

5. 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 revisionEuropean 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)

6. Eusoma Objectives for Breast Units • To make available for all women in Europe a high quality specialist Breast Service • To define standardsfor 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

7. 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

8. Eusoma Accreditation of Breast UnitsBasic Criteria A 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

9. Eusoma Accreditation of Breast UnitsBasic Criteria Sufficient cases to allow effective working and continuing expertise • Case load 150 newly diagnosed patients/year • ‘Surgeon’: 30 operations / year

10. 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

11. Case load • >< 30 new BC procedures/y: Survival RR: 0.85 < 10% have > 150 new cases/year 1/3 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

12. Case load per surgeon and outcome …D.M. Ingram et al; The Breast 2005

13. Case load per surgeon and outcome …D.M. Ingram et al; The Breast 2005

14. Hospital case load - extrapolated CM Files 2006

15. Univariate analysis of Survival according to Case LoadWomen 50 to 69 year - stage II CM Files 2006

16. Variations in relative survivalInvasive breast cancer BASO Breast Group West Midlands Cancer Intelligence Unit

17. Breast cancer mortality in trials of Polychemotherapy versus Not, entry age 50-69 Radiotherapy after BCS, generally with axillary clearance (BCSRT) in all women (pN0, PN+) EBCTCG

18. Eusoma Accreditation of Breast UnitsBasic Criteria Care by breast specialists in all the required disciplines Multidisciplinarity in all areas

19. Radiotherapy according to type of hospital - Stratification for age and stage of disease CM Files 2006

20. Treatment pattern according to case load – stratification for age (50-69) and stage of disease CM Files 2006

21. Eusoma Accreditation of Breast UnitsBasic Criteria Providing all necessary services: genetics, prevention, diagnosis, treatment, advanced disease and palliation Written, updated and evidence based protocols ‘Oncologisch Handboek’ ‘Individual patient decisions’

22. Participation in Screening Diagnosis: mammo, US, MRI; FNAC / CNB / VACNB / Stereotactic procedures Pathology 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) Care program with protocol

23. Eusoma Accreditation of Breast UnitsBasic Criteria Patient support for all patients - all stages Information Advocate Coach Buddy Guide Reduce anxiety ♀56 y; left mastectomy and ALND

24. Eusoma Accreditation of Breast UnitsBasic Criteria Data 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

25. QC in locoregional treatment- Eusoma GuidelinesTargets Pre-treatment tripel assessment • Palpable BC > 95% • FNAC/CNB in BC > 90% • NPBC, +FNAC/CNB > 80%

26. 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%

27. 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

28. Nucleair Med Genetic Counseling Palliative team Anaesthesia Fysiotherapy Psychologist Receptionist Logistics Nurses Out patient clinic GP Nurses Operation theatre Nurses Ward Radiologist Patient Partner children Nurses Day care unit Pathologist BCN Support Groups Breast Surgeon Gynaecologist Trial Nurse Prosthesis Cosmetic advice Wigs Radiation Oncologist Plastic surgeon Medical Oncologist Trainees BTB

29. 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!)

30. October 2006 Belgium: 6 Luxemburg: 1 France: 2 United Kingdom:1 Germany: 3 Netherlands: 1 Hungary: 1 Spain: 2 Italy: 5 Switzerland: 1 Portugal: 1 Slovenia: 1 http://www.cancerworld.org/ebcs/en/bs/Directory.asp

31. Facilitate physicians’ acceptance of guidelines by not imposing liabilityfor the failure to follow guidelines without determining the standard of care

32. The Belgian way?