of women and men with breast cancer within the region. One of the strategies adopted was to establish this ongoing quality assurance audit of breast cancer treatment. The project results presented here have been used by the Group membership to consider, and improve where possible, breast cancer treatment in the region.
Project design
The quality assurance project was a voluntary audit of treatment provided to patients within the region presenting with a new diagnosis of breast cancer. Patients with carcinoma in situ, with metastatic disease and men with breast cancer were included. Treatment and clinical details were recorded by the project after written informed consent of the patient was obtained. Ongoing follow-up data is being collected, which is focused on treatment outcomes including freedom from recurrence and disease specific and overall survival.
Participation
Participants in the project included 32 clinicians 21 surgeons, 4 radiation oncologists, and 7 medical oncologists) and 1266 patients. As enrolment into the project for patients was voluntary, complete coverage of all incident cases within the region was not possible. Indirect methods, include a comparison with registrations of the ACT Cancer Registry (where registration is compulsory) for the same period were performed. The estimated participation rate was 86% with possible under representation of older patients and those with stage 4 breast cancer.
Women with invasive breast cancer - main findings
Diagnosis:
Screening mammography detected 411 (38.1%) of the 1078 women presenting with unilateral invasive breast cancer. Screen detected cancers were smaller, and were more likely to be treated with breast conserving surgery than cancers presenting with clinical signs or symptoms.
Pathological features:
More than half (60%) of tumours removed surgically were less than 20 mm in diameter. Axillary lymph nodes were negative in 55.8% of cases. Oestrogen and/or progesterone receptors were routinely tested for and detected in almost 80% of tumours.
Surgery
Breast conserving surgery was performed for 48% of women with unilateral localised breast cancer. Of the 52% of women undergoing mastectomy, 20% initially underwent breast conserving tumour resection that was subsequently converted to mastectomy because of involved margins or the presence of extensive DCIS. The mastectomy rate was constant throughout the five years of the project, and was similar across age groups and place of residence (rural versus metropolitan). Although 743 women required only one operation, 305 women required two and 21 women required three operations to complete surgical treatment.
Axillary surgery of some form was received by 93% of women with invasive breast cancer. Of the 101 women not undergoing axillary surgery, 62 were aged 70 years or more. The majority of tumours in women not undergoing axillary surgery were smaller than 10 mm in diameter and grade 1. The treatment guidelines generally advise axillary surgery for all women with invasive breast cancer.
A rapid increase in the frequency of sentinel node biopsy was observed over the five year study period. Sentinel node biopsy is technically demanding, but when successful, avoids the need for more invasive axillary surgery in those patients where the sentinel node is negative for cancer. The expanding use of sentinel node biopsy may allow more women to safely avoid axillary lymph node dissection in the future.
Radiotherapy
Adjuvant post-operative radiotherapy is recommended for cases of invasive breast cancer after breast-conserving surgery, and for selected high risk cancers after mastectomy. After breast-conserving surgery 97% of patients received radiotherapy. Half of the patients not receiving radiotherapy after breast-conserving surgery were aged over 80 years.
Post mastectomy radiotherapy was received by 37.8% of women. Radiotherapy was more likely to be given to women with larger, node positive tumours. Women aged less than 50 years were much more likely to receive post mastectomy radiotherapy.
The absolute number of women receiving radiotherapy for operable breast cancer increased over the five year period. Increased delay in commencing radiotherapy following surgery was observed over this period largely due to constraints in radiotherapy services. The clinical effect is likely to be small.32, 33, 34
Chemotherapy
A striking increase in the use of adjuvant chemotherapy was observed during the study. The types of chemotherapy received also changed with anthracyline based combinations replacing CMF. The observed changes in chemotherapy practice have occurred during a period of increasing knowledge of the benefits of chemotherapy, but may also reflect an increase in the availability of medical oncology services during the five year study. Those women with higher risk tumours, and younger women were more likely to receive chemotherapy.
Hormonal therapy
Postoperative adjuvant hormonal therapy with tamoxifen was widely used in almost all patients with hormone receptor positive invasive cancer.
DCIS
Approximately 11% of women presented with unilateral DCIS during the study period. Most DCIS was diagnosed with screening mammography followed by core biopsy. Most patients with DCIS had breast conservation surgery with mastectomy undertaken for large, high-grade tumours. Post-operative radiotherapy was used only in the breast conservation patients. Selected patients received endocrine therapy, usually tamoxifen.
Future directions
The ACT & SE NSW Breast Cancer Treatment Group is committed to maintaining the project into the future. Data collection and registration of new patients is continuing. Ongoing, follow- up information is collected for each participating patient which should provide, over time, a picture of treatment outcomes. More detailed analysis of trends in the use of adjuvant systemic therapies for node negative patients is planned. It is expected that the audit database may support future research, possibly based around analysis of archival pathological material available for many of the participants.
The psychosocial care of patients and their families will receive more attention from the Group. To date, data collection has not included significant information around these issues. With an increased focus on multi-disciplinary care including the establishment of a regular ACT multi-disciplinary clinical meeting and the appointment of several breast care nurses, a more structured approach to breast cancer management has developed. Psychosocial support has become less haphazard. Additions to the data collection are anticipated which will allow the effectiveness of this care to be monitored over time.
Breast reconstruction after mastectomy is an important issue for women with breast cancer. Only very limited data has been collected about this issue by the Project to date. In particular, the decision making around early and late breast reconstruction, and the various techniques available, may be suitable subjects for data collection going forward. The underlying aim of the Project will remain to improve patient outcomes through informing health care professionals about the care they provide.
Support
The project has benefited from the commitment of ACT Health and Community Health, the dedication of the participating clinicians, the extremely high participation rates of patients, and the conscientious efforts of the Project team, in addition to the ongoing support from the multi-disciplinary Breast Cancer Treatment Group including effective consumer networks. The shared aim of improving breast cancer care on a community wide basis has been the foundation of this ongoing endeavour.