Monitoring care for female breast cancer patients in Northern Ireland diagnosed 2012

119 Pages·2016·3.38 MB·English

Monitoring care for female breast
cancer patients in Northern Ireland
diagnosed 2012 (with comparisons to
1996, 2001 and 2006)
N. Ireland
Cancer Registry page 1

Monitoring care of female breast cancer patients in
Northern Ireland diagnosed 2012 with comparisons
1996, 2001 and 2006
Edited by: Victoria Cairnduff, Deirdre Fitzpatrick, and Anna Gavin

This report should be cited as: Cairnduff V, Fitzpatrick D, Gavin A T. Monitoring care of
female breast cancer patients in N. Ireland diagnosed 2012 with comparisons 1996, 2001
and 2006. N. Ireland Cancer Registry 2015. Available at http://www.qub.ac.uk/nicr
N. Ireland
Cancer Registry page 2

Contents

FOREWORD ......................................................................................................................................... 4

ACKNOWLEDGEMENTS ................................................................................................................... 5

1. INTRODUCTION .......................................................................................................................... 6
1.1 Overview ................................................................................................................................ 6
1.2 Audit Aim ............................................................................................................................... 7
1.3 Breast Cancer Epidemiology and rates ............................................................................ 7
1.4 Background ......................................................................................................................... 15

2. Audit Methodology ..................................................................................................................... 19

3. Results ......................................................................................................................................... 20
3.1 Study Patients .......................................................................................................................... 20
3.2 Referral and presentation ....................................................................................................... 20
3.3 Family History........................................................................................................................... 22
3.4 Co-morbidities .......................................................................................................................... 23
3.5 Lifestyle Factors ....................................................................................................................... 24
3.6 Symptoms ................................................................................................................................. 26
3.7 Diagnosis and Staging work up ............................................................................................. 29
3.8 Treatment Modality .................................................................................................................. 35
3.9 Surgery ...................................................................................................................................... 39
3.10 Endocrine Therapy ................................................................................................................ 43
3.11 Timelines................................................................................................................................. 50
3.12 Information and Follow up care ........................................................................................... 56
3.13 Patient outcomes ................................................................................................................... 58

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N. Ireland
Cancer Registry page 3

4. BREAST CANCER SUMMARY ............................................................................................... 69
4.1 Study Patients .......................................................................................................................... 69
4.2 Referral and Presentation ...................................................................................................... 69
4.3 Family History, Co morbidities and lifestyle factors: 2012 Audit Subset ......................... 69
4.4 Symptoms: 2012 Audit Subset .............................................................................................. 70
4.5 Diagnosis: 2012 Audit Subset................................................................................................ 70
4.6 Treatment: 2012 Audit Subset ............................................................................................... 71
4.7 Timelines ................................................................................................................................... 72
4.8 Information and follow up care: 2012 Audit Subset ............................................................ 73
4.9 Patient Outcomes .................................................................................................................... 73
4.10 Conclusions ............................................................................................................................ 75
4.11 Recommendations ................................................................................................................ 75

References .......................................................................................................................................... 76

APPENDIX A –Summary of UK and NI breast cancer guidelines 1996-2011 .......................... 81
APPENDIX B – Staging of breast cancer ..................................................................................... 113
APPENDIX C - Incidence and mortality of breast cancer: 1993-2007 ..................................... 116

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N. Ireland
Cancer Registry page 4

FOREWORD

“Cancer services in Northern Ireland have improved in recent years. Developments have
spanned prevention, early detection and screening, diagnosis, management and palliative
care. The N. Ireland Cancer Registry has played an important role in monitoring this
progress.
This third report on breast cancer is very welcome. It is the eighteenth in a series of reports
on a wide range of cancers that examine in detail the pathways of care for patients. This
report provides a detailed insight into the diagnosis and care received by breast cancer
patients in 2012. By comparing with previous years, the report illustrates significant
improvement in services with evidence of greater concentration of specialist expertise, more
patients included in clinical trials, better access for most patients to a clinical nurse
specialist, and better targeting of treatments to yield most benefit for the patient.
Further improvement is possible particularly in ensuring equitable access to breast
reconstruction services.
This work confirms the value of undertaking regular reports to monitor the changing process
of diagnosis and treatment for cancer patients in Northern Ireland.”

Dr Carolyn Harper
Director of Public Health for Northern Ireland
October 2015

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N. Ireland
Cancer Registry page 5

ACKNOWLEDGEMENTS

The N. Ireland Cancer Registry is funded by the Public Health Agency of Northern Ireland
and this audit work was facilitated by a grant from the Guidelines and Audit Implementation
Network (GAIN) a unit within the Regulation & Quality Improvement Authority (RQIA).

The quality of data in this project is a result of the work of Bernadette Anderson and Clare
Marks (Tumour Verification Officers) who meticulously extracted detailed information from
clinical records for analysis and presentation in this report. Data abstraction was facilitated
by Colin Fox of the Registry’s IT team. The data analysis was undertaken by Dr Victoria
Cairnduff.

The work of the N. Ireland Cancer Registry, including the production of this report, is the
result of the work of the Registry team. I wish also to record my thanks to the Steering
Group and Council of the Registry who guide that work.

Anna Gavin
Director, NICR
2015

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N. Ireland
Cancer Registry page 6

1. INTRODUCTION
1.1 Overview
This Report is one of a series which examines in detail the pathway of care for cancer
patients in Northern Ireland. Over recent years there have been considerable changes in the
services provided to cancer patients. Starting almost 20 years ago the Campbell Report
‘Cancer Services: Investing for the future’ 1996, - resulted in a major reorganisation of
cancer services introducing:
 Management of patients by multidisciplinary teams
 Establishment of a single Cancer Centre and four other Cancer Units
 Centralisation of radiotherapy services to the Cancer Centre, with chemotherapy to
be made available in each Cancer Unit
 Review of palliative services
 Investment in oncology services
This was followed in 2008 by the introduction of targets to reduce cancer waiting times and
the development of an electronic Cancer Patient Pathway System (CaPPS) to facilitate the
work and management of the multidisciplinary teams.
Specifically for breast cancer, the most common cancer in women after non-melanoma skin
cancer, various guidelines have been produced over the years to enhance services and
outcomes. The main guidelines relating to breast cancer care are listed below and a
summary of the key recommendations from these documents are contained in appendix A.
 In 1997 the NHS produced guidance on commissioning cancer services: ‘Improving
outcomes in Breast Cancer’. This was updated in 2002 by the National Institute for
Health and Clinical Excellence (NICE) with five key recommendations.
 The British Association of Surgical Oncologists (BASO) produced nine
recommendations in ‘Guidelines for Surgeons in the Management of Symptomatic
Breast Disease in the United Kingdom’. (1995 updated in 2009).The referral
guidelines for suspected cancer published by NICE in 2005 containing 15
recommendations (4 general and 11 specific) regarding urgent referral for patients
with suspected breast cancer.
 In 2009 NICE published clinical guideline number 80 ‘Early and locally advanced
breast cancer: diagnosis and treatment’ and clinical guideline number 81 ‘Advanced
breast cancer: diagnosis and treatment’.
 In 2010 Breakthrough Breast Cancer published ‘Best practice diagnostic guidelines
for patients presenting with breast symptoms’.
 In 2011 the Department of Health London published ‘Improving outcomes: strategy
for cancer’.
 In 2011 NICE published the Breast cancer quality standard which contains 13 quality
standard standards of the management of early (invasive and in situ ductal
carcinomas) and advanced breast cancer.
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N. Ireland
Cancer Registry page 7

1.2 Audit Aim
To document the presentation, treatment and outcomes for female breast cancer patients
diagnosed in 2012 and compare with similar data collected in 1996, 2001 and 2006.
Areas the Audit will include:
1. Referral and presentation
2. Patient factors- lifestyle, family history, co morbidities and symptoms
3. Investigations, in particular pre-operative investigation techniques and tumour stage
4. Treatments
5. Patient survival
6. Multidisciplinary team meetings
7. Timelines from referral to presentation, investigations, and treatment
8. Surgeon case volumes
9. Patient information and follow up care

1.3 Breast Cancer Epidemiology and rates
Breast cancer is the most common cancer in women (excluding the less serious non
melanomas skin cancer). The number of patients diagnosed with breast cancer increased
from an average of 827 cases per year in 1993-1995 to an average of 1,268 cases per year
in 2009-2013. See figure 1.
Figure 1: Number of new breast cancer cases and deaths in Northern Ireland: 1993-
2013
1500
1250
s
e
s 1000
a
c
f
o 750
r
e
b
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u
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0
3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3
9 9 9 9 9 9 9 0 0 0 0 0 0 0 0 0 0 1 1 1 1
9 9 9 9 9 9 9 0 0 0 0 0 0 0 0 0 0 0 0 0 0
1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2 2 2 2
Year
Incidence (New cases) Mortality (Deaths)

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N. Ireland
Cancer Registry page 8

After accounting for the ageing population in Northern Ireland, an increase in breast cancer
incidence rates of an average of +1.3% per year between 1993 and 2013 was observed.
See figure 2.
During 2009-2013 there were 302 female deaths from breast cancer each year. It was the
second most common cause of death in women after lung cancer. Over the last ten years
the number of breast cancer deaths has not changed from 324 among women in 2004 to
313 among women in 2013. See figure 1. However when adjusted for age and population
change female breast cancer mortality rates decreased by -1.4% per year between 1993-
2013. See figure 2.
Figure 2: European age-standardised (EAS) incidence and mortality rates of breast
cancer in Northern Ireland: 1993-2013 using (1) 1976 European Standard population
and (2) 2013 European Standard population
s
e
la 180
m
e
f 160
0
0
0 140
,0
01 120
r
e
p 100
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ta 80
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a 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3
nae 991 991 991 991 991 991 991 002 002 002 002 002 002 002 002 002 002 102 102 102 102
p
o
r Year
u
E
1976 EAS Incidence Rate (observed) 2013 EAS Incidence rate (observed)
1976 EAS Mortality rate (observed) 2013 EAS Mortality rate (observed)
1976 EAS Incidence rate (modelled) 2013 EAS Incidence rate (modelled)
1976 EAS Mortality rate (modelled) 2013 EAS Mortality rate (modelled)

NOTE: Recently (2013) there was a change in the European Standard population against
which age-standardised rates are measured. This change was to take account of the
increasing age of the population and results in higher rates than with the previous standard
population (1976). The diagram above illustrates the differences. However both show a
steady increase in breast cancer incidence rates and a steady decrease in mortality rates.

Breast 2012
N. Ireland
Cancer Registry page 9

The lifetime risk of developing breast cancer in Northern Ireland is 1 in 11 and the risk is
higher in older than younger women. Overall the risk of developing breast cancer by the age
of 55 is 1 in 32 and before the age of 65 is 1 in 17 whilst the risk of developing breast cancer
before the age of 85 is 1 in 9.
Figure 3: Age distribution of patients diagnosed with breast cancer in Northern
Ireland: Number and age-specific rates: 2009-2013
180 450
160 ASR 400
140 350 )
R
r S
a
e 120 300 A
y re ( eta
p sesa 10800 220500 r ecne000,0
c d0
fo rebm 60 150 icni cifice1 rep
u 40 100 p
N S
-
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20 50 g
A
0 0
Age

Breast 2012