Inequalities in breast cancer care and outcome

The multicenter experience in the multidisciplinary Italian breast units: a review and update

A breast unit is a multidisciplinary center specialized in the management of women with breast diseases, including breast cancer (BC). It represents a care path, passing from screening activities to diagnostic investigations, from surgery to the definition of the therapeutic strategy, from psychophysical rehabilitation to long-term checks (follow-up), and up to genetic counseling. Since 2006, following a resolution issued by the European Parliament to urge member states to activate multidisciplinary breast centers by 2016, work has been underway throughout Italy to improve the management of women with BC. In Italy, the State-Regions agreement was signed on 18 December 2014, sanctioning the establishment of breast units. These centers must adhere to specific quality criteria and requirements. In 2020, the experts of the EUSOMA group (European Society of Breast Cancer Specialists), in their latest document published, expanded the requirements of the breast units. Furthermore, Senonetwork was founded in 2012 with the aim of allowing BC to be treated in breast units that comply with European requirements to ensure equal treatment opportunities for all Italian women. Indeed, the available data indicate that the BC patient has a greater chance of better treatment in the breast units with a multidisciplinary team, thus increasing the survival rate with a better quality of life, compared to those managed in nonspecialized structures. The present review is a perspective on the current Italian reality of breast units, updated with the available literature and the most recent epidemiological data from Senonetwork and AgeNaS.

Multidisciplinary breast centres in Germany: a review and update of quality assurance through benchmarking and certification

PURPOSE

This review summarizes the rationale for the creation of breast centres and discusses the studies conducted in Germany to obtain proof of principle for a voluntary, external benchmarking programme and proof of concept for third-party dual certification of breast centres and their mandatory quality management systems to the German Cancer Society (DKG) and German Society of Senology (DGS) Requirements of Breast Centres and ISO 9001 or similar. In addition, we report the most recent data on benchmarking and certification of breast centres in Germany.

METHODS

Review and summary of pertinent publications. Literature searches to identify additional relevant studies. Updates from the DKG/DGS programmes.

RESULTS AND CONCLUSIONS

Improvements in surrogate parameters as represented by structural and process quality indicators suggest that outcome quality is improving. The voluntary benchmarking programme has gained wide acceptance among DKG/DGS-certified breast centres. This is evidenced by early results from one of the largest studies in multidisciplinary cancer services research, initiated by the DKG and DGS to implement certified breast centres. The goal of establishing a nationwide network of certified breast centres in Germany can be considered largely achieved. Nonetheless the network still needs to be improved, and there is potential for optimization along the chain of care from mammography screening, interventional diagnosis and treatment through to follow-up. Specialization, guideline-concordant procedures as well as certification and recertification of breast centres remain essential to achieve further improvements in quality of breast cancer care and to stabilize and enhance the nationwide provision of high-quality breast cancer care.

Hospital volume and prognosis among Norwegian breast cancer patients enrolled in adjuvant trials

BACKGROUND

Several studies have reported an association between breast cancer unit volume and prognosis. We hypothesize that this may be due to inappropriate coping with the recommended guidelines for adjuvant therapy rather than improper breast cancer surgery provided at smaller units.

METHODS

A cohort of 1131 patients with operable breast cancer (pT(1-2) and positive axillary lymph nodes, stage II) enrolled between 1984 and 1994 were analyzed. The women had participated in one of three prospective trials on adjuvant endocrine treatment and were enrolled from 50 centers in Norway. The hospitals were categorized into four groups according to the annual number of surgically treated breast cancer patients reported to the national discharge database in 1990. The hospitals were also stratified according to whether they are university or non-university hospitals. To assess the effect of unit size on patient outcome, local recurrence rates and overall survival were compared in women treated at units with different patient volumes.

RESULTS

The median time from study enrolment to the end of the study was 10.5 years. Relapse-free survival and overall survival did not differ significantly between the hospital groups based on the surgical workload or between university and non-university hospitals.

CONCLUSIONS

Patient volume or teaching status of a hospital did not have any impact on the prognosis of pre- or postmenopausal stage II breast cancer patients included in the adjuvant endocrine trials. Our data support the hypothesis that differences in survival related to patient volume at the treatment units may be explained by inappropriate adjuvant systemic treatment.

Certification of breast centres in Germany: proof of concept for a prototypical example of quality assurance in multidisciplinary cancer care

Background

The main study objectives were: to develop a set of requirements of comprehensive breast centres; to establish a nationwide voluntary certification programme for breast centres based on such requirements, a certified quality management system (QMS), and scheduled independent, external audits and periodic recertification; and to demonstrate the general acceptance of such a certification programme with a view to introducing similar certification programmes for other major cancers.

Methods

Breast centres introduced a QMS and voluntarily participated in an external certification procedure based on guideline-derived Requirements of Breast Centres specifically developed for the application procedure, all subsequent audits and recertification. All data (numbers of pending and successful applications, sites/centre, etc.) were collected by a newly founded, independent organisation for certification of cancer services delivery. Data analysis was descriptive.

Results

Requirements of Breast Centres were developed by the German Cancer Society (DKG), the German Society of Senology (DGS) and other relevant specialist medical societies in the form of a questionnaire comprising 185 essential items based on evidence-based guidelines and the European Society of Breast Cancer Specialists' (EUSOMA) requirements of specialist breast units. From late 2002 to mid 2008, the number of participating breast centres rose from 1 to 175. As of mid 2008, 77% of an estimated 50,000 new breast cancers in Germany were diagnosed and treated at certified breast centres, 78% of which were single-site centres.

Conclusion

Nationwide voluntary certification of breast centres is feasible and well accepted in Germany. Dual certification of breast centres that involves certification of breast services to guideline-derived requirements in conjunction with independent certification of a mandatory QMS can serve as a model for other multidisciplinary site-specific cancer centres.

An informatics blueprint for healthcare quality information systems

There is a critical gap in our nation's ability to accurately measure and manage the quality of medical care. A robust healthcare quality information system (HQIS) has the potential to address this deficiency through the capture, codification, and analysis of information about patient treatments and related outcomes. Because non-technical issues often present the greatest challenges, this paper provides an overview of these socio-technical issues in building a successful HQIS, including the human, organizational, and knowledge management (KM) perspectives. Through an extensive literature review and direct experience in building a practical HQIS (the National Comprehensive Cancer Network Outcomes Research Database system), we have formulated an "informatics blueprint" to guide the development of such systems. While the blueprint was developed to facilitate healthcare quality information collection, management, analysis, and reporting, the concepts and advice provided may be extensible to the development of other types of clinical research information systems.

Regional differences in breast cancer survival despite common guidelines

PURPOSE

Despite a uniform regional breast cancer care program, breast cancer survival differs within regions. We therefore examined breast cancer survival in relation to differences in diagnostic activity, tumor characteristics, and treatment in seven Swedish counties within a single health care region.

METHODS

We conducted a population-based observational study using a clinical breast cancer register in one Swedish health care region. Eligible women (n = 7,656) ages 40 to 69 years diagnosed with primary breast cancer between 1992 and 2002 were followed up until 2003. The 7-year relative survival ratio was used to estimate breast cancer survival. Excess mortality was modeled using Poisson regression to study differences in survival between counties.

RESULTS

The 7-year relative survival for breast cancer patients was significantly lower (up to 7% in absolute risk difference) in one county (county A) compared with the others. This difference existed only among women diagnosed before 1998, ages 50 to 59 years, and was strongest among stage II breast cancer patients. Adjustment for amount of diagnostic activity eliminated the survival differences among the counties. The amount of diagnostic activity was also lower in county A during the same time period. After county A, during 1997-1998, began to adhere strictly to the regional breast cancer care program, neither any survival differences nor diagnostic activity differences were observed.

INTERPRETATIONS

Markers of diagnostic activity explained survival differences within our region, and the underlying mechanisms may be several. Low diagnostic activity may entail later diagnosis or inadequate characterization of the tumor and thereby missed treatment opportunities. Strengthening of multidisciplinary management of breast cancer can improve survival.

Quality control in breast cancer surgery

Quality assurance is the process by which quality care can be assessed. The general principles include setting a standard with the aim of achieving particular outcomes, followed by the evaluation of parameters that allow for quality assessment. Locoregional and survival outcomes are the major parameters but require years to evaluate and have other limitations. Other parameters therefore may assist in evaluation, such as the availability of the structures and processes required to achieve desired outcomes. Unlike chemotherapy and radiotherapy the quality of surgery is difficult to quantify, yet it is central to the issue of locoregional control and survival. In breast cancer surgery, quality control starts at the diagnostic service; from referral by the family practitioner to the appropriate triage of patients thereby preventing diagnostic delays. The surgical oncologist is pivotal in the multidisciplinary input necessary with both radiologists and pathologists in achieving the correct preoperative diagnoses of symptomatic and screen detected lesions as specified by many of the guidelines. Quality control of the operative surgery addresses issues such as training, volume and life audit of the surgeon. Standardisation of operative technique, pathology reporting with emphasis on specimen orientation and margins, management of the axilla and how it impacts on adjuvant treatment are other important issues. More recently, the availability of breast reconstruction services and the development of the oncoplastic surgeon is becoming an important quality issue. Finally, the quality of the follow up process provides the tools to assess the outcome of both the patient and the service.

First German disease management program for breast cancer

The first disease management program contract for breast cancer in Germany was signed in 2002 between the Association of Regional of Physicians in North-Rhine and the statutory health insurance companies in Rhineland. At the heart of this unique breast cancer disease management program is a patient-centered network of health care professionals. The program's main objectives are: (1) to improve the quality of treatment and post-operative care for breast cancer patients, (2) to provide timely information and consultation empowering the patient to participate in decisionmaking, (3) to improve the interface between inpatient and outpatient care, and (4) to increase the number of breast-conserving surgeries.

Monitoring surgical treatment of screen-detected breast lesions in Italy

The object of this study was to assess quality of care and adherence to treatment guidelines of screen-detected lesions in Italy using a new audit system. Data on screen-detected cases surgically treated in 1997 were collected using a system (QT 2.3) developed within the Italian Group for Planning and Evaluating Mammographic Screening Programmes (GISMa) and the European Breast Cancer Screening Network. Results of 18 performance parameters were considered compared with the reference standards. In 1997, 515 lesions (335 invasive, 60 in situ and 120 benign) in 496 patients were collected from 14 departments in the Central and Northern area of Italy. The 18 indicators were analysed and grouped according to six quality objectives. Some results were good and others were excellent, such as intraoperative identification, breast conservation surgery, adequate axillary procedures and completeness of pathology reports, but most of them failed: waiting times, preoperative diagnosis, employment of frozen section on small lesions and avoiding axillary procedures in ductal carcinoma-in-situ. This work is a first attempt in Italy to evaluate and uniform the criteria adopted for quality control of breast cancer treatment, using a standardised system. Some results are good or excellent, the overall level of compliance with quality indicators is not satisfactory and corrective actions should be undertaken for a number of issues. A continuous monitoring should be performed and appropriate action taken in order to verify the effectiveness of the corrective actions and to provide screen-detected patients with the best quality of care.

Widening disparity in survival between white and African-American patients with breast carcinoma treated in the U. S. Department of Defense Healthcare system

BACKGROUND

In the U. S., age-adjusted breast carcinoma mortality rates among white and African-American women have been diverging during the last 20 years. Some investigators speculate that the widening disparity is due to inequalities in access to healthcare, with African Americans having less access to necessary healthcare and improved therapies. Others argue that differences in tumor biology or some extrinsic influences on cancer etiology and behavior may account for the widening disparity. To examine this issue further, the authors compared trends in survival among white and African-American women diagnosed with breast carcinoma in the U. S. Department of Defense (DoD), an equal access healthcare system.

METHODS

The medical records of all women diagnosed with primary breast carcinoma between 1980-1999 were retrieved from the U. S. DoD Automated Central Tumor Registry (ACTUR). Variables selected for further analysis were date of diagnosis, date of birth, vital status and date of death if applicable, race (black, white, and others), and stage of tumor. Because the database does not contain causes of death, overall survival was investigated. The effect of year of diagnosis and race on overall survival was analyzed using the Cox proportional hazards model stratified by age at diagnosis (1-year age groups). Calculations were performed separately by disease stage for all stages combined and stratified by stage. Statistical analyses were performed using the statistical software package SAS.

RESULTS

After deleting observations with missing or implausible information regarding patient age, gender, and follow-up time, the final dataset was comprised of 23,612 women with primary breast carcinoma. The survival of African-American women compared with white women demonstrated an increasing ratio with calendar period. Although the hazard ratio was 1.269 for women diagnosed with breast carcinoma during the calendar period 1980-1984, it increased to 1.849 for those diagnosed between 1995-1999, which is a ratio of 1.46. For this period, the interaction between race and period was found to be significant (P = 0.04).

CONCLUSIONS

The results of the current study demonstrated that breast carcinoma survival rates among white and African-American patients, adjusted for age and stage, are diverging in the U. S. DoD healthcare system. Thus, inequalities in access to healthcare most likely are not solely responsible for the widening racial disparities in outcome reported among women diagnosed with breast carcinoma.

An economic evaluation of the optimal workload in treating surgical patients in a breast unit

A breast unit is a cancer centre specialised in the diagnosis and treatment of patients with breast cancer. The high level of specialised skills involved in running a breast unit makes it an expensive pattern of care. The European Society of Mastology (EUSOMA) recommends a minimum caseload of 150 cases sufficient to maintain expertise for each team member and to ensure cost-effective working of the breast unit. Specific economic analysis evaluating main diagnostic services (radiology and pathology) and treatment are needed. The present study assesses the activity level at which the breast unit represents good value for money in surgically-treated patients. Cost assessment is realised by defining a cost function according to the following assumptions: cost function input is personnel costs and technical equipment and output is the number of newly diagnosed cases of primary breast cancer admitted to the breast care unit each year. The increase from 50 new cancer cases per year to 100 will reduce average costs by almost 50%. Cost reduction is important up to a volume of 200 new cases per year. For economic investment to be justified, it is desirable that intake rises to at least 200 new cases per year. Our result is in-line with the EUSOMA recommendation.

The importance of quality assurance in surgical oncology

AIMS

The aims were to review the existing methods of quality assurance in surgical oncology and to determine a relationship between surgery-related factors and the variety in outcomes in the treatment of solid cancers.

METHODS

The literature was reviewed by searching Medline and Cancerlit databases.

RESULTS

Wide variations were found in virtually all tumour types. Clear evidence was found that an improvement in the quality of the surgical procedure could have major implications for the prognosis and quality of life of cancer patients.

CONCLUSIONS

These findings emphasize the need for strict quality control procedures in surgical oncology and might imply a considerable change in cancer treatment strategies, because the routine use of adjuvant therapies could be questioned.

Implementing clinical practice guidelines: a community-based audit of breast cancer treatment. Australian Capital Territory and South Eastern New South Wales Breast Cancer Treatment Group

OBJECTIVE

To improve breast cancer management by facilitating implementation of treatment guidelines.

DESIGN

A prospective, longitudinal study (developed by clinicians and consumers) of all patients with newly diagnosed breast cancer. Four locally agreed breast cancer management guidelines were established (based on 1995 National Health and Medical Research Council guidelines) as practice indicators.

SETTING

Breast cancer treatment facilities and medical practices in the Australian Capital Territory and South Eastern New South Wales, May 1997 to July 1998.

MAIN OUTCOME MEASURES

Actual treatment received by patients for primary breast cancer during the study period.

RESULTS

During the 14 months of the study, 19 clinicians registered 221 new patients with a proven diagnosis of breast cancer. Of 191 women with localised invasive breast cancer, 112 (59%) had tumours 2 cm or less in diameter. Axillary surgery in 173 (91%) of these women showed 107 (56%) had no axillary lymph node involvement. Of 87 women treated with breast-conserving surgery for locally invasive cancer, 85 (98%) also received postoperative radiotherapy. Some form of systemic adjuvant therapy was indicated in 99 women (axillary nodes positive or tumours > 2 cm diameter) and this treatment was received by 95 (96%). All 27 women aged under 50 years with node-positive disease received adjuvant chemotherapy.

CONCLUSIONS

Enhancing uptake of breast cancer management guidelines is feasible at a regional level with an audit program and broad support among clinicians and consumers.

Variation in the survival of women with breast cancer in Scotland. The Scottish Breast Cancer Focus Group and The Scottish Cancer Therapy Network

We have investigated factors influencing the survival of women with early breast cancer in Scotland. In a retrospective study, clinical, treatment and 'service' factors, e.g. surgical case load, deprivation and geographical area (health board of first treatment) were recorded from hospital records. A total of 2148 women with invasive breast cancer diagnosed in 1987 were identified from the Scottish Cancer Registry, of whom 1619 without metastases at diagnosis underwent surgery as part of their primary treatment. In a multivariate analysis, clinical factors (age, clinical stage, pathological tumour size, node status and oestrogen receptor status) all influenced survival. After allowing for these clinical factors, surgical case load and deprivation did not have statistically significant effects on survival. By contrast, health board did affect survival. This was explained in part by the selection of patients for surgery. There appeared, however, to be a residual effect that may be related to differences in the use of adjuvant systemic treatment among the different health boards. We conclude that, in Scotland, geographical variation in both surgical and non-surgical treatment has a greater effect on variability in survival for women with breast cancer than surgical case load and deprivation.