Annual Report 2012 - Breast - FINAL · Successful bid for ongoing funding of the running costs for OSNA this year and to extend the technique in the new merged breast unit when this

University Hospitals Bristol NHS Foundation Trust

0117 923 0000 Minicom 0117 934 9869 www.uhbristol.nhs.uk

Annual Report Breast MDT

2 Annual Report - Breast MDT

Agreement and Approval

Breast MDT Lead Clinician Zen Rayter

Date 14/09/2012 Signature (agreed via email)

Review Date

Annual Report Review Date: 01/07/13 (as part of North Bristol MDT)

Versions

Version Date Reason Sign Off

2.1 01/04/09 Draft revision for 2009 Peer Review



5.0 July 2012 Revision for 2012 Peer Review 14/09/2012

Annual Report - Breast MDT 3

1 Measure Checklist

Measure Number

Measure Operational Policy

Annual Report

Work Plan

Supporting Information

11-2B-101 Lead Clinician and Core Team Membership p10, p12

11-2B-102 Level 2 Practitioners for Psychological Support

p19

11-2B-103 Support for Level 2 Practitioners p19 p4

11-2B-104 Team Attendance at NSSG Meetings p8

11-2B-105 MDT Meeting p14, p16

11-2B-106 MDT Agreed Cover Arrangements for Core Members

p10

11-2B-107 Core Members (or Cover) Present for 2/3 of Meetings

p8

11-2B-108 Annual Meeting to Discuss Operational Policy

p15 p5

11-2B-109 Policy for All New Patients to be Reviewed by MDT

p14

11-2B-110 Policy for Communication of Diagnosis to GP p18 p16 p9

11-2B-111 Operational Policy for Named Key Worker p19 p16 p9

11-2B-112 Core MDT Clinical Consultants 50% Time on Breast Cancer

p11

11-2B-113 Core MDT Nurse Spends 50% Time on Breast Cancer

p11

11-2B-114 Core Histopathology Member Taking Part in Histopathology EQA

p15 p16

11-2B-115 Core Nurse Member Completed Specialist Study

p13

11-2B-116 Agreed Responsibilities for Core Nurse Members

p13

11-2B-117 Attendance at National Advanced Communication Skills Training Programme

p12 p5

11-2B-118 Extended Membership of MDT p11

11-2B-119 Patient Permanent Consultation Record p18 p10

11-2B-120 Patient Experience Exercise p21 p18 p7 p11

11-2B-121 Provision of Written Patient Information p18, p22

11-2B-122 Agree and Record Individual Patient Treatment Plans

p15 p13

11-2B-123 MDT Agreement to Network Clinical Guidelines

p20

11-2B-124 MDT Agreement to Network Referral Guidelines

p20

11-2B-125 MDT Agreement to Network Imaging Guidelines

p20

11-2B-126 MDT Agreement to Network Pathology p20


Measure Number

Measure Operational Policy

Annual Report

Work Plan

Supporting Information

Guidelines

11-2B-127 MDT Agreement to Network Guidelines for Early Breast Cancer Follow Up

p20

11-2B-128 Agreed Collection of Minimum Dataset p21 p13

11-2B-129 Network Audit p21 p15-16 p8

11-2B-130 Agreed List of Approved Trials p21 p18 p9

11-2B-131 Workload of at Least 100 New Patients/Year p9

11-2B-132 Joint Treatment Planning for TYA Patients p16-17 p11


2 Contents

1 Measure Checklist ......................................................................................................................... 3

2 Contents ........................................................................................................................................ 5

3 Introduction .................................................................................................................................... 6 3.1 Key Achievements ................................................................................................................ 6 3.2 Key Challenges ..................................................................................................................... 7

4 Meeting Details .............................................................................................................................. 8 4.1 Attendance At NSSG Meetings ............................................................................................. 8 4.2 Core MDT Meeting Attendance ............................................................................................. 8

4.2.1 Attendance by Role ........................................................................................................... 8 4.2.2 Attendance by Individual ................................................................................................... 8

4.3 Workload of MDT / Cases Discussed .................................................................................... 9 4.3.1 Breast cancer surgery by operating surgeon (UH Bristol only) ......................................... 10 4.3.2 Number of patients receiving immediate reconstruction ................................................... 11

4.4 Meetings to Discuss Operational Policies ............................................................................ 11 4.4.1 Monthly Business Meetings ............................................................................................. 11 4.4.2 Annual General Meeting .................................................................................................. 11

4.5 TYA patients ....................................................................................................................... 11

5 Training ....................................................................................................................................... 12 5.1 Advanced Communication Skills ......................................................................................... 12 5.2 Other Training ..................................................................................................................... 12 5.3 Level 2 Psychological Support Training ............................................................................... 12

6 Data Collection ............................................................................................................................ 13 6.1 Clinical Lines of Enquiry ...................................................................................................... 13

7 National / Local Audit ................................................................................................................... 15 7.1 Network and Local Audit - completed .................................................................................. 15 7.2 Network and local audit – current/ongoing ........................................................................... 15 7.3 Audit Of Diagnostic Notification To GPs And Key Worker.................................................... 16 7.4 EQA Audit ........................................................................................................................... 16

8 Research ..................................................................................................................................... 17 8.1 Clinical Trials .......................................................................... Error! Bookmark not defined.

9 Patient and Carer Feedback and Involvement ............................................................................. 18 9.1 National Cancer Patient Experience Survey Findings............. Error! Bookmark not defined. 9.2 Actions arising ........................................................................ Error! Bookmark not defined. 9.3 Improvements as a result of previous exercises ..................... Error! Bookmark not defined.


3 Introduction

This report relates to the operational period April 2011 – March 2012. This period has seen a number of issues, challenges and successes as outlined below.

3.1 Key Achievements

Consolidation of the use of One Step Nucleic Acid Amplification for the diagnosis of metastases in sentinel lymph nodes. We have now gone live with over 300 cases and continue to prevent second operations in patients whose lymph nodes are positive.

Successful bid for ongoing funding of the running costs for OSNA this year and to extend the technique in the new merged breast unit when this takes place in late 2012.

Consolidation of MRI biopsy for lesions in the breast only seen on MRI scanning and we have become the regional centre for this technique.

Adherence to all access targets for patients with breast disease including outpatient waits and inpatient waits.

Successful completion of 23-hour stay for patients undergoing surgery for breast cancer with the lowest stay in the cancer network (average 19.6 hours).

Completion of audits on preoperative axillary ultrasound in patients with breast cancer demonstrating a detection rate of 50% in patients with macrometastases.

Completion of an audit on the effect of referral of patients with PIP implants on the workload of the unit.

Completion of randomized controlled trial on the use of TISSEEL glue on the donor site in latissimus dorsi flap reconstruction published in British Journal of Surgery 2012 (see research).

Completion of the 12 month study: A Multi-centre prospective cohort study evaluating the integration of Patient Reported Outcome Measures (PROMS) with key clinical outcomes after immediate Latissimus Dorsi (LD) breast reconstruction and adjuvant treatment with publication in the British Journal of Surgery 2012 (see research).

Completion of the phase 2 study: The early development phases of a European Organisation for Research and Treatment of Cancer (EORTC) module to assess Patient Reported Outcomes (PROs) in women undergoing breast reconstruction in a multicenter European trial with recruitment of 96 patients. For publication in European Journal of Cancer 2012 (see research).

Launch of QUEST trial in breast reconstruction with randomization of 21 patients to trials A and B The QUEST Perspectives Study has recruited 46 patients to date (see research).

Presentations by the junior doctors in the unit resulted in 3 prizes:

o The Norman Tanner Medal of the Section of Surgery of the Royal Society of Medicine

o Association of Surgeons in Training Prize for best poster presentation

o John Farndon Prize for best scientific presentation at the South West Surgeons meeting in October 2011.


Introduction of the D DISH technique to measure HER 2 expression in breast cancer.

3.2 Key Challenges

The main challenge is the future merger of the 2 Bristol Breast Units. The uncertainty surrounding this has resulted in the loss of administrative staff which have only slowly been replaced and has resulted in poor communication between the different departments within the breast unit, which has been detrimental to its smooth functioning.

Continuing to meet the targets in the face of increasing demand.


4 Meeting Details

4.1 Attendance At NSSG Meetings (11-2B-104)

The Breast NSSG met on the following dates for the year 2011 / 2012. The MDT was represented as follows.

Meeting Date Name Job Title

22nd

June 2011 Zenon Rayter

Monica Lamont

Consultant Surgeon and MDT Lead

Imaging Specialist

29th September 2011 Mark Beresford*

Alexandra Valencia

Consultant Oncologist

Imaging Specialist

% attendance 100

* Dr Beresford was a core member of the MDT at the time of the SSG meeting

Full details of these meetings can be found in the Network Annual Report

4.2 Core MDT Meeting Attendance (11-2B-107)

A full breakdown of MDT meeting attendance for core MDT members for period April 2011 – to March 2012 is as follows.

4.2.1 Attendance by Role

Role Combined Attendance (%)

Two Designated Breast Surgeons 86% (100% at least one)

Oncologist 92%

Two Imaging Specialists 98% (100% at least one)

Two Histopathology Specialists 51% (100% at least one)

Two Clinical Nurse Specialists 100%

MDT Co-ordinator 94%

4.2.2 Attendance by Individual

Name Job Title % attendance 11/12

Zenon Rayter Lead Clinician for MDT 80.39%

Zoe Winters Breast Surgeon 64.71%

Jim Cook Breast Surgeon 84.31%

Chris Price Oncologist 76.47%

Nar Thanvi (joined November 2011) Oncologist 77.78%

Amit Bahl Oncologist 74.51%

Elizabeth Kutt Imaging Specialist 78.43%

Angela Jones Imaging Specialist 82.35%

Monica Lamont Imaging Specialist 78.43%


Alexandra Valencia Imaging Specialist 72.55%

Caroline Calder Histopathologist 68.63%

Mohammed Sohail Histopathologist 74.51%

Angie Nicholson Clinical Nurse Specialist 84.31%

Lorraine Peall Clinical Nurse Specialist 76.47%

Caroline Radford Clinical Nurse Specialist 84.31%

Miranda Cooper Clinical Nurse Specialist 80.39%

Dan Brown MDT Service Co-ordinator 74.51%

4.3 Workload of MDT / Cases Discussed (11-7B-131)

The table below shows the number of new diagnoses of breast cancer at UH Bristol between 01/04/2011-31/03/2012, by first treatment type. Please note some of these patients may have gone on to have further treatments of other types.

First treatment type Number of new diagnoses - primary

Number of new diagnoses - recurrence

Number of new diagnoses - metastasis

Active Monitoring 1 0 1

Anti Cancer Drug (Cytotoxic Chemotherapy) 51 4 27

Anti Cancer Drug (Hormone Therapy) 32 4 2

Surgery 200 9 1

Teletherapy (Beam Radiation excl. Proton Therapy) 43 2 77

Not recorded* 18 0 8

Total 345 17 116

* - Treatment may not have commenced at time report was generated. Patients with metastasis may have had treatment recorded against primary cancer. Please note that some treatments may have been carried out by other providers e.g. screening cases diagnosed at UHB and referred to local providers (Weston, NBT etc.) for discussion and treatment.

The number of new patients discussed is well in excess of the minimum standard of 100 per year.


4.3.1 Breast cancer surgery by operating surgeon (UH Bristol only)

Patients undergoing procedures for diagnoses of C50*,D05* and D24X in financial year 2011/12, as per PAS system. Please note these diagnoses are assigned by the clinical coding team and therefore may be based on the suspected diagnosis at time of admission and not the final histologically determined diagnosis. The number of cases below therefore will not match the number of cases given surgery above (also will include some cases were surgery was given as a subsequent treatment).

Procedure ZE WINTERS

J COOK

Z RAYTER

B271 - Mastectomy + excision of both pectoral muscles + part of chest wall 1

B273 - Mastectomy + excision of pectoralis muscle 1

B274 - Mastectomy 14 9 35

B275 - Mastectomy - Subcutaneous 1

B276 - Mastectomy - Skin sparing (Envelope) 13 5 17

B281 - Segmentectomy/Quadrantectomy 1

B282 - Wide local excision 8 6 29

B283 - Excision biopsy 4 1 24

B285 - Wire guided partial excision of breast 29 6 51

B287 - Wire guided excision of lesion of breast 7 3 12

B322 - Biopsy of lesion of breast 1

B341 - Sub-areolar excision of mammillary duct 1

B344 - Microdochotomy 1

B352 - Excision of nipple 2

B353 - Extirpation of lesion of nipple 1

S069 - Excision of sebaceous cyst 1

Grand Total 78 30 176

Footnote: these figures do not elaborate on the specific types of breast reconstruction procedure performed.

Two patients in the original data appeared to have been operated on by non-breast surgeons, however following investigation both were shown to be data error and have therefore been removed.

The table below shows the same data but for procedures undertaken in the 2010/11 financial year.

Procedure ZE WINTERS J COOK Z RAYTER

B273 - Mastectomy + excision of pectoralis muscle 1



B282 - Wide local excision 9 6 21

B283 - Excision biopsy 13 1 27

B285 - Wire guided partial excision of breast 15 3 24

B287 - Wire guided excision of lesion of breast 3 2 7

B344 - Microdochotomy 2

Grand Total 57 18 131


Footnote: these figures do not elaborate on the specific types of breast reconstruction procedure performed.

Five patients in the original data appeared to have been operated on by non-breast surgeons, however following investigation all were shown to be data error and have therefore been removed.

4.3.2 Number of patients receiving immediate reconstruction

There is currently no way of measuring the number of patients offered immediate reconstruction. The table below shows the number of patients having a mastectomy or segmentectomy/quadrantectomy in 2011/12 who underwent immediate reconstruction (56%).

Immediate Reconstruction

Procedure No Yes Grand Total

B271 - Mastectomy + excision of both pectoral muscles + part of chest wall 1 1

B273 - Mastectomy + excision of pectoralis muscle 1 1


B275 - Mastectomy - Subcutaneous 1 1


B281 - Segmentectomy/Quadrantectomy 1 1

Grand Total 43 54 97 Footnote: these figures do not elaborate on the specific types of breast reconstruction procedure performed.

4.4 Meetings to Discuss Operational Policies

4.4.1 Monthly Business Meetings

The MDT holds regular business meetings at the end of each month. All core members are invited to attend. The meeting is used to discuss operational and service improvement issues.

4.4.2 Annual General Meeting

This was held on 9th February 2012 and minutes are included in the supporting information on pages 5-8.

4.5 TYA patients (117B-132)

There was one patient in the TYA age range treated for breast cancer in the review period. The patient was not referred to the TYA MDaT. The operational policy now includes the policy for referring on all patients in the age range, and the TYA MDaT is working on a tool to help identify TYAs diagnosed in the Trust, which should ensure future patients get referred.


5 Training

The staff in the Unit undertake a wide variety of training and learning opportunities to continually improve practice in the Unit.

5.1 Advanced Communication Skills (11-7B-117)

The following core MDT members with direct patient contact have attended this training:

Zenon Rayter, 21-23 June 2010

Jim Cook, 20-22nd September 2011

Zoe Winters, February 2012

Miranda Cooper, 20-22 April 2010

Angie Nicholson, 23-25 November 2010

Lorraine Peall, 23-25 November 2010

Caroline Radford 30 November – 2 December 2010.

Elisabeth Kutt 9-11 August 2010

Angela Jones 18-20 January 2010

Monica Lamont 18-20 January 2010

Alexandra Valencia 23-25 November 2010

Amit Bahl 7th-12th December 2009

Chris Price and Nar Thanvi have not yet been able to attend this training and are awaiting further course dates to become available.

5.2 Other Training

The consultants continue to attend National and International meetings to keep up to date with the latest advances in breast cancer.

5.3 Level 2 Psychological Support Training (11-7B-102,103)

The Breast CNSs are trained to provide level 2 psychological support to patients and undergo monthly clinical supervision with the clinical psychology team. The timetable is available in the supporting information on page 4.


6 Data Collection (11-7B-128)

The team and Trust continue to work on improving data collection. The Somerset Cancer Register is used to collect information and tools are being developed to better monitor completeness of clinical data, based on those currently in use to monitor waiting times data.

The agreed network SSG Dataset can be found at http://www.aswcs.nhs.uk/main.cfm?type=BRST.

An audit of data completeness for key fields in the CQUIN dataset has been completed, with a focus on improving these areas of data collection as appropriate. Note this relates to completeness of the cancer register only; information may be available on other systems e.g. theatres system, pathology system etc. Some areas have already undergone a significant improvement since these figures were collated, for example CNS contact recording.

Data item % Completeness 11/12*

SNOMED code recorded (on SCR) 96%

Pathology report recorded (on SCR) 39%

Treatment intent recorded 80%

Primary procedure recorded 100%

Date of admission/treatment start date recorded 100%

Diagnosis recorded 100%

TNM staging (NB not widely used for breast cancer) recorded 6%

CNS contact recorded 11%

MDT discussion recorded 100%

* Prior to data completeness improvement exercises

6.1 Clinical Lines of Enquiry

Clinical Lines of Enquiry are this year based on the Service Profile developed for Breast MDTs nationally. The below information comments on those areas where the service significantly differs from the England average. Most of these are positive findings and reflect a large screening service and a commitment to immediate reconstruction in suitable patients. Specific comments have been included against any other areas.

Patients aged seventy or older – Trust has significantly fewer than average. This is a demographic factor.

Patients with a nationally registered Nottingham Prognostic Indicator – the Trust is significantly better at registering this than the national average. There is also a significantly higher number of patients who have NPI of ‘good or excellent’.

Number of patients with invasive cancer treated at Trust – significantly higher than average.

Number of patients with non-invasive cancer treated at the Trust are significantly lower than average. This figure is inaccurate. It records only one patient as having been treated which is incorrect. It is

http://www.aswcs.nhs.uk/main.cfm?type=BRST


likely that this is due to a problem with recording on the cancer register, which will be investigated and rectified for future.

Episodes following an emergency admission – this measures proportion of all admissions for breast cancer that are by an emergency method (as opposed to elective). Day case surgery is not included (therefore a higher percentage of day case surgery compared to other Trusts could skew the figures). Trust is significantly higher than England average. The numbers are thought to be due to patients coming in as emergency admissions with an unrelated problem and then found to have cancer. An audit will be undertaken to establish if this is the case.

Patients referred by breast screening service – significantly higher than England average.

Surgical cases receiving sentinel lymph node biopsy are significantly lower than the England average. The MDT queries the accuracy of this figure. The Trust performs 150 sentinel node biopsies per year, whereas the Service Profile information only records 52 cases. Patients who are diagnosed with lymph node metastases by preoperative axillary ultrasound and fine needle aspiration cytology do not require a sentinel node procedure.

Mastectomy patients receiving immediate reconstruction – significantly higher than England average. (Please note that that we have not included a breakdown of the types of Breast reconstructions in the breakdown of procedures by Surgeon).

First outpatient appointments as a proportion of all outpatient appointments are significantly higher than England average


7 National / Local Audit

7.1 Network and Local Audit – completed (11-7B-129)

The team participates in the Network audits and in addition has an active local audit programme. The team has completed an audit of ‘One Step Nucleic Amplification of Sentinel Lymph Nodes’.

The objectives were as follows:

PRIMARY:

• Comparison of OSNA with traditional histopathology in order to delineate concordance of results

• To determine the proportion of patients who could avoid secondary axillary surgery

SECONDARY:

• To determine the proportion of Micrometastases and presence of further positive nodes in those who undergo Level 1 axillary clearance

• To determine the proportion of Macrometastases and presence of further positive nodes (Micro and Macro), in those who undergo Level 3 axillary clearance

• To determine the impact on operating times of OSNA

The results are summarised below:

• 54 patients (26.6%) saved a second procedure

• Median waiting time 20 mins

• No relationship between tumour characteristics and nodal status

• Sensitivity 93%

• Specificity 94% (if exclude micromets)

• No nodal tissue left for receptor analysis

7.2 Network and local audit – current/ongoing

The Network audit into routes to diagnosis was presented at the September meeting of the NSSG. UHB participated in the audit. The audit showed 3% breast cancer patients across the Network were diagnosed following emergency admission. The audit highlighted differences in recording data between Trusts and as a result the Network organised a meeting of breast MDT coordinators to discuss improving consistency. This took place in February 2012 at UHB.

The team is currently participating in the following ongoing audits:

An audit of referrals related to PIP implants

An audit of the results of neoadjuvant chemotherapy in breast cancer


An audit of the findings on sentinel lymph node biopsy prior to the start of neadjuvant chemotherapy.

Evaluation of DDISH, a new light microscopy technique for assessment of Her2 status

Comparison of tumour grade between core biopsy and excision specimen

Evaluation of Roche ultraview universal detection system for assessment of HER2 immunohistochemically using 4B5 antibody.

7.3 Audit Of Diagnostic Notification To GPs And Key Worker (11-7B-110, 111)

A sample of 20 case notes were pulled. These were then assessed against the standard of GP notification within 24 hours of diagnosis and whether a key worker had been assigned.

100% notes had key worker details clearly recorded as per the policy

100% notes showed GP notified within 24 hours of the patient being given their diagnosis

Actions: Continue to use fax proforma and ensure all new staff are educated in its use.

7.4 EQA Audit (11-7B-114)

The UH Bristol pathology service has full CPA accreditation across its labs.

The core pathologists, Caroline Calder and Muhammed Sohail, participate in the NHSBSP EQA scheme. The scheme is anonymised and does not provide certificates, which makes meaningful documentary evidence difficult to obtain. Both also participate in the general EQA scheme. This has been verified with the Pathology Manager.


8 Research (11-7B-130)

The MDT is actively involved in research and a number of trials. The table below shows recruitment to open trials at UH Bristol. The first two trials are the NSSG’s endorsed trials. These figures were presented to the NSSG by Mr Rayter and discussed on 19th April 2012.

Trial Name Recruitment

POETIC 7

SUPREMO 10

TNT 4

MOSS 2

Import-High 7

D-CARE 2

LANTERN 2

BIG 3-07 1

FAST FORWARD 4

UH Bristol confirmed it would not cap fractions of radiotherapy for patients participating in the Fast Forward/BIG 3-07 trials from other Trusts, allowing these trials to be opened at other locations in the Network. There were no other actions identified as necessary to improve recruitment at UH Bristol.

There are several surgical trials with a Bristol led Chief Investigator (Dr. ZE Winters):

A multi-centre UK feasibility trial called QUEST A and B. This trial is evaluating the acceptability of randomisation in all women undergoing types and timings of LD breast reconstruction, as well as assessing PROMS (patient reported outcome measures) as primary outcomes in main trial. Fifteen centres opened in September 2011 and 21 patients have been randomized to date (15 to Trial A) and 6 to (Trial B), with 40 patients recruited into QUEST Perspectives Study which is a qualitative study. This is the first randomised multi-centre study.

A five-centre European trial developing the first European validated breast reconstruction specific PROM (patient reported outcome measure), assessing health related quality of life after all types of breast reconstruction. A total of over 150 patients have been recruited to date. A paper from this trial will be published in European Journal of Cancer 012 (under revision).

Six-centre UK prospective longitudinal cohort study on over 200 patients since 2007 evaluating PROMS after types of LD breast reconstruction with and without radiotherapy. A paper from this trial is in press in the British Journal of Surgery 012 (DOI: 10.1002/bjs.8959).

Completion of first randomised trial evaluating effects of fibrin sealant on donor site seromas after types of LD breast reconstruction. 100 patients were randomised at a single Bristol centre. The paper is in press in the British Journal of Surgery 012 (DOI: 10.1002/bjs.8874).


9 Patient and Carer Feedback and Involvement (11-7B-120)

The National Cancer Patient Experience Survey 2011/12 reported shortly before the self-assessment was completed. The MDT and Trust are formulating an action plan based on the results. Full results for the breast MDT are available in the supporting information on pages 11-12.

193 breast cancer patients responded to the survey.

Strong areas were:

- Patients were told they could get free prescriptions

- Hospital staff always did everything they could to control pain all the time

- Surgery date not changed by hospital

- Staff told patient who to contact if had worries after discharge

- Always given enough privacy when being examined/treated

Areas where the MDT scored significantly lower than the national average, and therefore to be improved, were:

- Patient’s views definitely taken into account when discussing treatment

- Always given enough privacy when discussing treatment/condition

- Patient offered written assessment and care plan

- Patient waiting times in clinics

Actions from the previous survey include improvements the availability of patient information on benefits and financial matters, and results suggest this has been successful. The breast MDT developed an NSSG-wide patient leaflet on metastasis to improve information for this patient group.

Documents

Annual Report 2012 - Breast - FINAL · Successful bid for ongoing funding of the running costs for OSNA this year and to extend the technique in the new merged breast unit when this