The NICE Breast Cancer Quality Standards - Are they helpful and how are we doing against them?E APPLETON, J NAIK

What are the breast cancer quality standards?

“This quality standard describes markers of high-quality, cost-effective care that, when delivered collectively, should contribute to improving the effectiveness, safety and experience of care for adults with breast cancer…”

Preventing people from dying prematurely.Enhancing quality of life for people with long-term conditions.Helping people to recover from episodes of ill health.Ensuring that people have a positive experience of care. Treating and caring for people in a safe environment and protecting them

from avoidable harm.

What are the breast cancer quality standards?

3: Breast Conserving

Surgery

1: Referral 5: Pathology – ER/HER2

Status8:

Adjuvant Therapy Planning

2: Clinical Assessment 7: Staging

10: Follow Up

Imaging

9: Clinical Follow Up

12: Key Worker

13: Brain Metastasis

11: MDT6:

Management

4: Mastectomy

How should we use them? Not intended as a set of targets or mandatory indicators for performance management Aim is to drive up standard of care i.e. target 100% (or 0% if a negative outcome) Provide an opportunity to -Evaluate the service as a whole – local +/- regionalEngage with the wider MDT Improve patient care Improve Peer Review measures

Challenges presented –Quantity of outcomes Clarity of some statements

How should we use them? Quantity -

13 outcomes, 12 protocols, ~ 36 outcomes/audits Who does what/when? Difficulty keeping track…

What was done Prior audit in Mid yorks (presented May 2014) – separate audits covering all the auditable quality standards Long and labour-intensive process (started in 2012) Aim was to devise a more efficient/focused method of re-auditing services. Audit tool -

◦ Focused on key areas identified from the previous audit◦ Attempted to facilitate easier data entry◦ Aim to standardise for future audits◦ Rolled out across the network (Responses from Leeds and Bradford)

Demographics/process 235 patients across 3 sites, diagnosed Sept-Dec 2014 (3 month period)

Data collection done by multiple team members (varied among trusts – 2 from Leeds, 1 from Brad and multiple from MY).

Data then analysed centrally, with some input from local teams when anomalies were encountered.

Leeds MY Brad

Female 79 Female 80 Female 73Male 1 Male 2 Male 070+ 29 70+ 33 70+ 18<70 51 <70 49 <70 55Total 80 Total 82 Total 73

Total YCN 235

Results - Radiology/clinical assessment

Did the patient receive a pre-

treatment USS of the axilla

If positive, did they receive a needle

biopsy (FNA/core)

If needle biopsy was negative, did

they receive a SNB

Did they undergo >1 axillary

operation eg SNB followed by ANC

“People with early invasive breast cancer are offered a pre-treatment ultrasound evaluation of the axilla and, if abnormal lymph nodes are identified, ultrasound-guided needle biopsy (fine needle aspiration or core). Those with no evidence of lymph node involvement on needle biopsy are offered sentinel lymph node biopsy when axillary surgery is performed”

Results - Radiology/clinical assessment

Pre Tx USS Needle Bx if +ve USS SNB if -ve Bx Patients undergoing >1 axillary operation

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Clinical assessment

Leeds MY Brad Cross site

Leeds MY Brad Cross site0

20

40

60

80

100

% FNA vs Core Bx

FNA Core

Results – Radiology/clinical assessment

Good! 231/235 patients received a pre treatment USS 98/100 patients with a positive USS received a needle biopsy 72/74 patients with negative needle biopsies received a SNB Only 23 patients underwent >1 axillary operation (11%)

All deviations explained by patient choice or condition. 1 patient had an MRI axilla over USS, 1 patient was unfit for further investigation following diagnosis, 1 developed a PE prior to SNB, and 1 had locally advanced disease confirmed on punch biopsy. Rates of re-operation low across the network. Majority FNA over core (80% vs 20%) Recommendation Continue current management

Results - Breast conserving surgery

“People with early breast cancer undergoing breast conserving surgery, which may include the use of oncoplastic techniques, have an operation that both minimises local recurrence and achieves a good aesthetic outcome.”

Did the patient undergo breast

conserving surgery

Was there a need for re-operation

Number of re-operations

Results - Breast conserving surgery

Leeds MY Brad Cross site0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

55%

39%

58%

50%

5%

15%21%

14%

Breast conserving surgery

Rate of BCS Rate of reoperation

Results – Breast conserving surgery

114/226 surgical candidates underwent BCS 16/114 had more than one operation, with a delay in definitive surgical management of 27-72 days (although one slightly anomalous at 224 days)

Lower BCS rates in MY over this period (prev 63% in 2012) ? Case review/review of data

Re-operation rates Very low in Leeds – can anything be learnt from this? Rest near/within the EUSOMA gold standard figure of 20% Significant decrease in MY (33% 15% from previous audit)

May be some variability due to interpretation by those collecting data – eg some said “Yes” to re-op, but annotated as a further axillary operation, or evacuation of a haematoma.

Recommendations More detailed audit to evaluate the trends/conclusions

Results - Pathology (ER and HER2 status)

Quality statement

“People with newly diagnosed invasive breast cancer and those with recurrent disease (if clinically appropriate) have the ER and HER2 status of the tumour assessed and the results made available within 2 weeks to allow planning of systemic treatment by the multidisciplinary team.”

Was the patients ER status assessed

at time of diagnosis or recurrence?

Was the patients HER2 status

assessed at time of diagnosis or recurrence

Were results for both HER2 and ER

status available within 2 weeks

Results – Pathology ER/HER2 status

ER st

atus asse

ssed

HER2 status a

ssesse

d

Both resu

lts av

ailable w

ithin 2 w

eeks0%

40%

80%

120%Assessment of ER/HER2 status

Leeds MY Brad

%

ER status HER2 status0%

20%

40%

60%

80%

100%

120%

Availability of results within 2 weeks

Leeds MY Brad

%

Results Done well across the region Only delays were in HER2 testing, most awaiting dDISH Lower percentage of HER2 results available within 2 weeks from BRI – is there anything that can be learnt from this or is it just a statistical quirk/feature of the sample period? Predictably more reliable in tertiary centre – testing done on-siteRecommendations? any value in taking a closer look at HER2 results in BRI (may be that this is not an issue!)

Results - Management“People with early invasive breast cancer, irrespective of age, are offered surgery, radiotherapy and appropriate systemic therapy, unless significant comorbidity precludes it.”

If TNBC, did the patient receive

adjuvant chemo (or NACT)

Did the patient receive

radiotherapy post BCS

Grouped into patients older and younger than 70

Results

Chemo in TNBC <70 70+0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Chemo in TNBC - Cross site

Leeds MY Brad0%

20%

40%

60%

80%

100%

Chemo in TNBC

Leeds MY Brad0%

20%40%60%80%

100%

Age distribution - chemo in TNBC

<70 70+

Results - Chemotherapy 22 TNBC patients identified across the 3 sites

Only 3 patients did not receive chemotherapy – either due to patient choice or condition. All 3 patients were in the >70 age group

All TNBC patients <70 received adjuvant/neoadjuvant chemotherapy.

Appropriate use of therapeutic options in TNBC, meeting high standards across the network

Confusion on the audit tool – adjuvant and NACT – need to clarify!

Recommendations

Continue current management

Results - Radiotherapy

RT post BCS <70 70+0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

RT post BCS - cross site

Leeds MY Brad0%

20%40%60%80%

100%RT post BCS

Leeds MY Brad0%

10%20%30%40%50%60%70%80%90%

100%

Age distribution - RT post BCS

<70 70+

Results - Radiotherapy Of the BCS patients, only 6 did not have post-op radiotherapy in this sample

Mostly documented as being due to patient choice or condition

Group of patients not undergoing radiotherapy predictably made up of a higher proportion of >70s

Meets high standards across the region

Recommendation

Continue current management

Results - Patient information“People having treatment for early breast cancer are offered personalised information and support, including a written follow-up care plan and details of how to contact a named healthcare professional”

Did the patient receive a written

information pack regarding the different treatments available to them and

possible side effects?

Did the patient receive written information re dates of follow

up, adjuvant therapy review

and surveillance?

Did the patient receive contact

details of a named

healthcare professional?

Did the patient receive

information about the available

psychological and emotional

support?

Results – Patient information

Leeds MY Brad0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Patient information

Treatments/side effects Follow upContact details Emotional/psychological support

Results – patient information Provided the most variable results across the audit standards Difficult data to access retrospectively Bradford do especially well - entry added directly into PPM when primary information pack is given, with documented evidence of multiple documents for treatment info/support. May be variation within people collecting data – do junior doctors have different standards to specialist nurses who, for example, do the information giving on a daily basis?

Recommendations Use of a standardised method of information giving/recording Could review pack where already in use to check it contains follow up details etc (or make sure this is recorded elsewhere) May need to evaluate what aspects of this standard are actually important (do patients necessarily read/need more information to improve their experience?

The process What went well –

Large amount of data collected in a relatively short amount of time Provides a “snapshot” of service provision across the region Enables discussion between units as to how to improve services where results are variable Could become a method of repeatedly auditing services on a larger regional/national scale.

What could be improved – Difficulty when multiple people collect data – data quality, clarity of exceptions etc Need to clarify some of the standards for ease of data collection Audit tool maybe too rigid – more space to input data freely in order to improve data quality and analysis. Some technological blips in audit spreadsheet – to be smartened up a bit if used again!

Where next? Identified key areas for further audit With some deeper thought into the ergonomics/content could be a good yearly benchmark across the region ? Participation across more centres ? Input from others as to what to include/way of improving data quality/participation

Thanks to Luke Wreglesworth (LTHT), Mandy Blackburn (BRI), Julie Davies, Leanne Howard, Debbie Hepworth, Michele Smith, Helmy Mashaly, Deviner Gupta and Parisha Bisram (MY) for collecting the audit data.

Thankyou! Any questions?