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FOR HEALTH AND SOCIAL CARE

National Mastectomy and Breast Reconstruction Audit A national audit of provision and outcomes of mastectomy and breast reconstruction surgery for women in England and Wales

First Annual Report of the National Mastectomy and Breast Reconstruction Audit 2008

Prepared in association with:

3 of 47Copyright © 2008, The NHS Information Centre, National Mastectomy and Breast Reconstruction Audit. All rights reserved.

National Mastectomy and Breast Reconstruction Audit

A national audit of provision and outcomes of mastectomy and breast reconstruction surgery for women in England and Wales

Prepared in association with:

National Mastectomy and BreastReconstruction Audit

A national audit of provision and outcomes of mastectomy and breast reconstructionsurgery for women in England and Wales

First Annual Report of the National Mastectomy and Breast Reconstruction Audit 2008

This is the first annual report from the National Mastectomy andBreast Reconstruction Audit. The report presents the first year’swork on the project including a pre-audit qualitative study,Hospital Episode Statistics (HES) analysis and organisational audit.

The National Mastectomy and Breast Reconstruction Audit collectsinformation on all women (aged 16 and over) who undergomastectomy and/or breast reconstruction between 1 January and30 September 2008 in both the NHS and Independent sector. Theresults of the clinical data collection and patient reportedoutcomes study will be reported in subsequent reports starting inDecember 2008.

The aim of the audit is to describe provision of and access tobreast reconstruction in England and Wales. Evaluate currentclinical practice in mastectomy and breast reconstruction andmeasure outcomes following mastectomy with or withoutreconstruction and assess the quality of information provided towomen undergoing mastectomy and their satisfaction with thereconstructive choices made.

The National Mastectomy and Breast Reconstruction Audit reportis available to download from: http://www.ic.nhs.uk/mbr

Printed copies of this report can be ordered from The NHSInformation Centre’s Contact Centre 0845 300 6016 or email:[email protected] quoting document reference 18120107.

For further information about this report, contact The NHSInformation Centre’s Contact Centre 0845 300 6016 or email:[email protected].


Information at the heart of decision making in health and social care

Contents

1.0 Acknowledgements 6

2.0 Forewords 7

3.0 Executive Summary 8

4.0 Background 11

5.0 Details of audit/Introduction 13

6.0 Qualitative Study 15

7.0 Organisational Survey 19

8.0 Hospital Episode Statistics (HES) on 23the number of breast cancer operationperformed in England, 1997 – 2006

9.0 Discussion 26

10.0 Conclusion 29

Appendix 1 Prospective Data Collection 30Data Sheets

Appendix 2 Organisational Representatives 39

Appendix 3 Contributing Organisations 40

Glossary 45

References 47


1.0 Acknowledgements

The National Mastectomy and Breast ReconstructionAudit is managed by the National Clinical AuditSupport Programme (NCASP) and is funded by theHealthcare Commission.

The Project Team would like to thank the membersof the Clinical Reference Group (Chair, DickRainsbury) for overseeing the delivery of the auditand providing clinical guidance as well as themembers of the Project Board (Chair, Martin Old) forproviding project governance. A list of members ofthe Clinical Reference Group and Project Board isprovided in Appendix 2.

The Project Team would also like to acknowledgethe support of Marialena Trivella, ClinicalEffectiveness Unit, for carrying out the analysis ofHospital Episode Statistics data.

Finally, we would like to thank all stakeholders whoparticipated in the qualitative study and all NHSTrusts and private hospitals who providedinformation for the organisational study.

This report was prepared by:

Clinical Effectiveness Unit, Royal College ofSurgeons of EnglandRanjeet Jeevan, Research FellowJohn Browne, Senior Lecturer in health services researchJan van der Meulen, Director

Association of Breast Surgeons at the BritishAssociation of Surgical OncologyJerome Pereira, Breast Surgeon

British Association of Plastic, Reconstructive andAesthetic SurgeonsChris Caddy, Plastic Surgeon

Royal College of NursingCarmel Sheppard, Breast Care Nurse

The NHS Information Centre for health and social careCaroline McGregor-Johnson, Project ManagerZaki Kramer, Business and Project Support OfficerSteve Dean, Senior Project Manager


2.0 Foreword

I am writing this at the end of January 2008. We’reoff! We’ve started the audit. My impression so far is that it is a bit like the start of the GrandNational.

To continue the racing analogy, the race has got offto a rapid start with the appearance of a largenumber of horses in the first month. Thanks to allthose who have registered so far.

The results in this annual report highlight theimportance of carrying out a comparative clinicalaudit. Please remember that unlike many audits,where one completes a form and never know theresult, this audit will allow hospitals to read theirown inputted data. Hospitals will be able tocompare their own results against a nationalaverage in real time through online reporting.

The ABS has a proud tradition of audit in breastcancer. The MBR audit is a unique, challenging anddifficult audit which will benefit future generationsof women with breast cancer. I urge you to givethis your full support.

Once again, thank you for your enthusiasticparticipation - and the best of luck at Beecher’s!

Hugh BishopAssociation of Breast Surgery at British Association of Surgical Oncology

I am delighted to be given this opportunity of writingin support of what must be considered to be one ofthe most ambitious projects yet carried out in thefield of breast cancer reconstruction. The forwardthinking of those surgeons from general and plasticsurgery with an interest in breast surgery to form theInterface Breast Training Group of the Royal Collegeof Surgeons of England was in itself revolutionary.The embarkation of this organisation on a four yearnational audit of the standard of care deliverednationally to women with breast cancer cannot beapplauded highly enough. The results of the first yearof this audit have revealed the real rather than theperceived situation as it stands today, identifying thesignificant problems being faced by breast surgeonsin this era of ever decreasing ‘targets’ for the deliveryof care. Bringing these facts to the surface and intothe public arena must herald significant improvementin the management of this unfortunate group ofpatients. I very much look forward to reading theresults of the next three reports, confident in thebelief that this improvement will have been achievedand would like to proffer my appreciation andrecognition of the enormous effort and dedicationput in by those orchestrating this survey.

A. Roger Green FRCSPresidentBritish Association of Plastic, Reconstructive and Aesthetic Surgeons


3.0 Executive Summary

The National Mastectomy and Breast ReconstructionAudit Project began on 1 January 2007. The keyquestions that the audit aims to answer are:

• is the provision of breast reconstruction servicesuniform across England and Wales?

• do women undergoing mastectomy have enoughinformation to make an informed decision aboutbreast reconstruction, and are they happy withthat decision?

• what are the outcomes following mastectomywith or without breast reconstruction?

In 2002, the National Institute for Clinical Excellence(NICE) published the report ‘Improving Outcomes inBreast Cancer’1 that contained guidance on theorganisation and delivery of services for people withbreast cancer. Further guidance was published bythe Association of Breast Surgery (ABS) at the BritishAssociation of Surgical Oncology (BASO) and theBritish Association of Plastic, Reconstructive andAesthetic Surgeons (BAPRAS).2 The keyrecommendations are that:

• all breast cancer patients should be managed bymulti-disciplinary teams

• breast reconstruction should be available at theinitial surgical operation

• breast cancer referrals should only be made to unitswhich deal with at least 100 new cases per year

• there should be regular network-level audits ofservice provision and the outcomes attained,including an assessment of patients’ and carers’experiences.

The National Mastectomy and Breast ReconstructionAudit is designed as a four year project. The focus ofthe audit will be a prospective examination of thedeterminants of variation in practice and outcomesfor a cohort of women who will undergomastectomy or reconstruction surgery during 2008.However, the audit also aims to provide a full pictureof breast cancer services in England and Wales. Toenable this, three additional pieces of work wereperformed in 2007 to investigate those aspects noteasily addressed through prospective data collectionat the individual patient level.

These comprised:

• a qualitative study of interviews with 30stakeholders to highlight the characteristics ofhigh quality surgical care for women with breastcancer and so inform the design of the clinicaldataset and patient questionnaires to be used inthe prospective audit

• an organisational survey of 144 NHS Trusts (93 percent response rate) and 143 private hospitals (88 per cent response rate) to identify thecharacteristics of healthcare providers eligible forparticipation in the prospective audit

• a retrospective analysis of the Hospital EpisodeStatistics (HES) dataset to describe changes in thenumber of breast cancer operations performed inthe English NHS between 1997 and 2006 andhence indicate the approximate number to becovered by the prospective audit.

The results of this additional work are presented inthis first annual report. The main findings aresummarised below.

Overall quality of breast cancer surgery

• Among the stakeholders who were interviewedfor the qualitative study, there is a generalperception that a good surgical service is availableto women with breast cancer in England andWales. There is a strong consensus amongstakeholders about the determinants of highquality in breast cancer surgery. The followingseven determinants were identified from thestakeholders’ responses:

• service configuration

• resources

• communication with patients

• time to allow informed and reasoned decisionmaking

• training of staff

• communication between clinicians

• defining and auditing quality standards andoutcomes.


Service configuration

• There are considerable pressures upon serviceproviders. These include the need to provide moreoperations because of the rising incidence ofbreast cancer and the requirement to provide ahigher proportion of women with reconstructiveoptions after mastectomy. Service providers in theEnglish NHS responded to these pressures byincreasing the number of operations performedfrom 24,684 to 33,814 over the period 1997 to2006, a 37 per cent increase.

• The number of immediate reconstructionprocedures provided by the English NHS almostdoubled between 1997 and 2006. However, theproportion of all women undergoing mastectomywho received an immediate reconstructionincreased only from 7 per cent to 11 per cent. Thisindicates that there have been difficulties inimplementing guidance that immediatereconstruction should be made available to allwomen undergoing mastectomy.

• Local access to breast reconstruction services isnot uniform across England and Wales. Althoughfalling in number, 39 English NHS Trusts (26 percent) that performed mastectomy surgery in2005-06 did not also provide immediatereconstruction as a local option according to HES.

• There is considerable variation between andwithin the NHS and private sectors with respect tothe use of chemotherapy before surgery to enablethe offer of an immediate reconstruction. 55 percent of NHS Trusts would provide the option ofsuch therapy to a woman with metastatic diseasewhile 45 per cent would not. 72 per cent ofprivate hospitals said they would provide thisoption to women with metastatic disease. Thevariation observed is likely to create inequities inaccess to immediate breast reconstruction.

Resources

• There is a perception that the current fundingclimate within the NHS creates disincentives toincrease access to breast reconstruction. Someservice commissioners may create barriers to theavailability of breast reconstruction by, for example,insisting upon a psychological evaluation. Someservice providers have responded to resourceshortages by ring fencing hospital beds for breastcancer patients.

Communication with patients

• Breast care nurses have a key role in supportingpatients through the decision about whether ornot to have a breast reconstruction at the sametime as their mastectomy. Seven NHS Trustemploy only one such nurse. This means patientsmay be unable to access specialist nursing care ifthe sole nurse is away on annual or sick leave. 11per cent of private hospitals providing breastcancer surgery report that they do not directlyemploy a breast care nurse. The 2002 NICE report,states that a specialist breast care nurse should beavailable to all patients with breast cancer, andinvolved as a core member of any breast cancermulti-disciplinary team.

Time to allow informed and reasoned decisionmaking

• The decision to proceed with immediate breastreconstruction is difficult and women requireadequate time to digest the information andchoices available. There is a perception thatdecisions about reconstruction are often relegatedto a secondary concern because of the urgentneed to move the patient to definitive treatmentwithin the 62 day window laid down by the 2000NHS Cancer Plan.


Training of staff

• In 2005-2006, one third of all the English NHSTrusts that performed breast reconstructionsurgery for women performed less than six suchprocedures, indicating that reconstruction surgeryis still performed at Trusts with relatively littleexperience in the field. These centres provide apoor environment for surgeons to train andimprove their breast reconstruction skills. Therecent ABS and BAPRAS guidance recommendsthat a caseload of at least 25 major reconstructiveprocedures per annum is required for a Trust to berecognised as an oncoplastic training unit.

• One encouraging development is the breakdownin surgical specialty boundaries as evidenced, forexample, by the 80 NHS Trusts who report thatgeneral surgeons with a specialty interest in breastsurgery now perform pedicle flap breastreconstructions. The innovative oncoplastic breasttraining programme established by BAPRAS andthe ABS may have stimulated this development.

Communication between clinicians

• A fifth of the NHS Trusts that perform breastcancer surgery do not have a consultantoncologist, pathologist or radiologist with aspecialist interest in breast cancer within the Trust.This may impair the quality of diagnostic servicesand adjuvant (non-surgical) therapy planning forwomen treated at these centres. The 2002 NICEreport, states that these consultants are coremembers of the multi-disciplinary team and areessential to providing appropriate diagnostic andtherapeutic services.

• 94 per cent of private hospitals report that theneeds of their breast cancer surgery patients arediscussed at a multi-disciplinary team elsewhere.This may impair the quality and speed of decisionmaking about breast reconstruction for thesepatients and inhibit local efforts to audit thequality of care although quantitative evidence tosupport this claim is not yet available.

• The prospective audit will allow for a moredetailed investigation of the relationship betweenmulti-disciplinary team structures and the qualityof care provided.

Defining and auditing quality standards andoutcomes

• 90 per cent of NHS Trusts and 61 per cent ofprivate hospitals contribute to one or morenational clinical datasets on breast cancer care.However, most of these datasets contain onlylimited information on surgical practices andoutcomes. This makes it difficult to understandthe reasons why some women do or do notproceed to breast reconstruction aftermastectomy. The National Mastectomy and BreastReconstruction Audit has been designed toremedy this information deficit and it is hopedthat all NHS and private centres carrying outbreast cancer surgery in England and Wales willparticipate.


4.0 Background

4.1 Breast cancer treatment

Breast cancer is the most common form of femalecancer, accounting for nearly 30 per cent of all casesof cancer in women. There were 39,301 new casesof breast cancer amongst women in England andWales in 2004, an increase of 27 per cent over 10years. 10,969 women died from the disease in 2005(Office for National Statistics).3,4,5 Breast cancer canalso occur in men but this form of the disease is notdiscussed hereafter.

Women with breast symptoms are usually referred bytheir GP to a breast specialist for a triple assessment.Triple assessment involves a clinical examination ofthe breast; a form of breast imaging – usuallyultrasound in young women and mammography inolder women; and a cell or tissue sample being takenfrom the abnormal area. The results of this tripleassessment will decide the diagnosis and any furthertreatments that may be provided. A second routeinto the treatment pathway is via the NHS BreastScreening Programme. All women between 50 and70 are invited to undergo regular screening, theintention being to pick up cancers that are notpalpable (capable of being felt). The screeningassessment may be performed at a hospital or mobileunit, and involves mammography of the breast. Theimages are then reviewed and reported on by aspecialist who decides if there are any suspiciousfindings. If these are present, the woman is referredto a breast specialist in a screening programme clinicto undergo a full triple assessment and proceed totreatment as necessary.

Surgery continues to be the first line treatment forbreast cancer for many women. The treatment ofearly breast cancer may involve removal of part ofthe breast tissue (breast conserving surgery) or allbreast tissue (mastectomy). In either case, surgerymay also be required to restore the cosmeticappearance following loss of breast tissue.

4.2 Development of breast cancer surgery

The goal of breast cancer treatment has shifted froma traditional emphasis on tumour ablation to therapydesigned to restore the patient to wholeness,providing the maximum possible quality of life whilecontrolling malignancy. Through collaborationbetween plastic and breast surgeons there havebeen significant enhancements in service delivery to

patients with breast cancer. The Breast OncoplasticService is defined as a core component of the breastmulti-disciplinary team with sufficient experience tooffer patients access to the full range of proceduresencompassed by oncoplastic breast reconstructivesurgery, which include:

• appropriate adequate surgery to extirpate thecancer

• partial reconstruction to correct wide excisiondefects

• immediate and delayed total reconstruction withaccess to a full range of techniques

• correction of asymmetry of the reconstructed andthe contralateral unaffected breast.2

4.2.1 Mastectomy

Mastectomy is recommended when the breastwould be significantly distorted by the removal of alarge cancer, when the tumour is directly behind thenipple, when the cancer is multi-focal (in more thanone area of the breast), or where there arewidespread lesions within the breast. The type ofmastectomy depends on many factors such as size oftumour, location and tumour type and whether thepatient intends to undergo reconstructive surgery.Some women may also have a preference formastectomy rather than breast conserving surgery.

4.2.2 Breast reconstruction

Breast reconstruction is an operation to create abreast shape to match the remaining breast andregain symmetry following mastectomy. This can bedone either at the same time as the initialmastectomy or at a later stage. The decision forimmediate reconstruction versus delayedreconstruction will depend on a number of clinicalissues (adjuvant treatment plans) as well as patientchoice. In line with guidance issued by NICE in 2002,breast reconstruction should be discussed with allpatients who require mastectomy.5

There are several different techniques used toreconstruct a breast, these include:

• implant-only reconstruction

• ‘autologous’ reconstruction using the patient’sown tissue

• a combination of both these methods.


Tissue reconstruction most commonly involvesmoving a ‘flap’ of skin, muscle and fat from thepatient’s back or abdomen to the breast area, whilekeeping intact a ‘pedicle’ or tube of tissuecontaining its supplying arteries and veins. ‘Free flap’reconstruction involves the tissue being completelydetached from the donor area before it is moved,with microsurgery used to rejoin its arteries and veinsto those in the breast area. This technique meansthat tissue can also be taken from areas not adjacentto the breast, such as the buttock or thigh.

4.3 Background to the audit

Rising public awareness, heightened traineeexpectations and growing collaboration betweenbreast and plastic surgeons were the catalyst thattriggered the formation of an Interface BreastTraining Group at the Royal College of Surgeons ofEngland in 2000. This group was established toimprove the availability and outcomes of breastreconstruction for patients through better educationand training, both for breast and for plastic surgeonsat all levels of experience. The Interface Group wassupported by BAPRAS and by the ABS, and theirsubcommittees.

The early developmental work carried out by thisgroup led to two new initiatives that have propelledthe debate about breast reconstruction onto thenational stage. The original proposal for a nationalaudit was submitted to the Commission forHealthcare Audit and Inspection in 2003, and wasresubmitted to the Healthcare Commission in 2005.An amended audit proposal was submittedsuccessfully to the Commission the following year.The National Mastectomy and Breast ReconstructionAudit is the first of its kind in the world, and willinclude all women in England and Wales undergoingmastectomy as well as all those undergoingimmediate and delayed breast reconstruction.


5.0 Details of audit/Introduction

Breast reconstruction following mastectomy forbreast cancer is an evolving area of care in Englandand Wales. Different techniques for reconstructionhave been introduced in recent years, and as a resultthere is considerable variation in the practices ofdifferent healthcare providers. There is also variationin the larger issue of patient indications forreconstruction, with uncertainty about the safety ofimmediate reconstruction in certain patients. As aresult there is the potential for geographicalinequities in care, with the likelihood of beingoffered breast reconstruction often depending onthe hospital at which a patient is treated.

5.1 Key questions

The key questions to be addressed in the audit are:

• is the provision of breast reconstruction servicesuniform across England and Wales?

• do women undergoing mastectomy have enoughinformation to make an informed decision aboutbreast reconstruction, and are they happy withthat decision?

• what are the outcomes following mastectomywith or without breast reconstruction?

To address the key questions listed above the audithas six objectives.

• To quantify the current volume of reconstructionsurgery performed in England and Wales at bothNHS and private centres.

• To explain reasons for variation in access to anduptake of reconstruction, such as patientcharacteristics (e.g. co-morbidities), andhealthcare provider processes (e.g. type ofinformation and advice given to patients).

• To describe current clinical practices in breastcancer surgery, and to explain variation in practiceusing data on patient characteristics andhealthcare provider identity.

• To describe outcomes following mastectomy withor without reconstruction. Both patient reportedoutcomes (e.g. satisfaction and quality of life), andclinical outcomes (e.g. peri operativecomplications, local cancer recurrence andsurvival) will be collected (within the timetable ofthe audit).

• To explain variation in outcomes using data onpatient characteristics, tumour characteristics,clinical practices and identity of healthcare provider.

• To address nationally agreed standards. Asevidence based standards are unavailable atpresent the focus of the audit will be onproducing standards rather than auditing againstsuch standards.

5.2 The design of the audit

The focus of the audit will be a prospective audit of acohort of women undergoing breast cancer surgerythat includes the collection of clinical and patientreported outcomes data. Women who undergomastectomy and breast reconstruction surgery duringthe first nine months of 2008 will be included.

In addition, the audit includes three additional piecesof work which were performed in 2007. Theseinvestigated aspects of service provision that are noteasily addressed with prospective data collection onthe treatment of individual women and theiroutcomes. The three pieces of work were:

• a qualitative study of interviews with 30stakeholders to highlight the characteristics ofhigh quality surgical care for women with breastcancer and so inform the dataset and patientquestionnaires to be used in the prospective audit

• an organisational survey of 144 NHS Trusts and143 private hospitals carried out to identify thecharacteristics of healthcare providers eligible forparticipation in the prospective audit

• a retrospective analysis of the HES dataset todescribe changes in the number of breast canceroperations performed in the English NHS between1997 and 2006 and indicate the approximatenumber of operations that will be covered by theprospective audit.

In 2007, there has been considerable effort toprepare for the prospective audit component of theproject, including design of a clinical dataset andpatient questionnaires, a pilot project andrecruitment of NHS and private hospitals. Tofacilitate the latter task, five ‘roadshows’ took placearound the country. Prospective data collectionbegan on 1 January 2008 and will run till 30


September 2008. To date more than 100 NHS trustsand 50 private hospitals have registered to take partin the prospective study. Private hospitalparticipation has been actively encouraged by thosewho accredit such units for breast cancer surgeryand insurers such as BUPA.

5.3 Annual reports

This project will take four years to complete.Planning and feasibility work began on 1 January2007. In this first annual report the results of thequalitative study, organisational survey andretrospective analysis of HES are presented.

The second annual report (December 2008) willprovide a more complete analysis of existingdatasets. In addition to an analysis of existing dataheld by the Patient Episode Database Wales (PEDW),it will report on an attempt to combine HES andCancer Registry data available for the last nine years.It will also provide an analysis of clinical datacollected in the prospective audit. For example:

• description of patients’ demographic and clinicalcharacteristics

• description of clinical practices

• explaining variation in patient characteristics andclinical practices

• describing peri-operative outcomes e.g.complications

• explaining variation in peri-operative outcomes.

The third annual report (December 2009) will answerall questions that can be covered by analysis ofquestionnaires completed by patients three monthsafter surgery. For example:

• appropriateness of information and adviceprovided about breast reconstruction

• reconstructive choice offered and planned infuture

• post-discharge complications and intervention

• the relationship between clinical risk factorsidentified during the peri-operative period and thepatient’s care experience.

The fourth annual report (December 2010) willanswer all questions that can be covered by analysisof eighteen month patient reported outcomequestionnaires. For example:

• levels of patient quality of life, function andsatisfaction

• the relationship between clinical risk factorsidentified during the peri-operative period and theeighteen-month patient reported outcomes.

5.4 The project team

This audit is a collaboration between the Associationof Breast Surgeons at the British Association ofSurgical Oncology, the British Association of PlasticReconstructive and Aesthetic Surgeons and theRoyal College of Nursing, supported by the ClinicalEffectiveness Unit at the Royal College of Surgeonsof England and the National Clinical Audit SupportProgramme (NCASP) at The NHS Information Centrefor health and social care. All of these organisationshave a long standing interest in the audit of breastcancer surgery and are delighted that the HealthcareCommission has decided to prioritise and fund thisnational clinical audit of mastectomy and breastreconstruction.


6.0 The challenges of delivering highquality breast care surgery service: a qualitative studyAs the first step in this audit, a qualitative study wascarried out to identify the most serious deficiencies inthe quality of current care. This study aimed toidentify opportunities to improve the quality of breastcancer surgery from the perspective of patients,clinicians and others involved in commissioning andproviding the service. It was also hoped that the studywould involve stakeholders from the outset toencourage “ownership” of the audit.

The specific objectives were:

• to define what constituted high quality care forpatients undergoing breast cancer surgery

• to identify current problems in effectivelydelivering this care

• to inform the design of the clinical dataset andpatient questionnaires to be used in theprospective audit.

Over a three-month period in 2007, thirtystakeholders with experience and knowledge of thecare delivered to patients with breast cancer wereinterviewed. The sample comprised:

• five patients

• two patient representatives from the voluntarysector

• one breast surgeon not performing reconstruction

• four breast surgeons performing reconstruction

• four plastic surgeons

• two breast care nurses

• one anaesthetist

• one radiologist

• one oncologist

• one physiotherapist

• two private healthcare representatives

• one Cancer Registry lead

• one Cancer Network lead

• one Welsh Assembly representative

• two Department of Health representativesinvolved in cancer policy formulation

• one audit lead at the Healthcare Commission.

Seventeen interviewees were members of the audit’sClinical Reference Group (CRG) and the remaining13 were nominated by the CRG’s members to coverareas in which additional information was deemednecessary. A semi-structured interview format wasused to identify the key determinants of quality inbreast cancer surgery.

The following sections summarise the results ofthese interviews. Qualitative methods are anaccepted means for addressing complex aspects ofhealthcare provision and identifying conceptualthemes.

Definition of high quality care for patientsundergoing breast cancer surgery

Overall, many interviewees, patients as well ashealthcare professionals, indicated that “generallyspeaking it all works very well.” Surgeons said thatthey felt that they were able to deliver areconstruction to everybody who wants it and thatover a period of time “an environment (was created)where everything works.”

An analysis of the interviews highlighted sevencharacteristics of high quality care:

• service configuration

• resources

• communication with patients

• time to allow informed and reasoned decisionmaking

• training of staff

• communication between clinicians

• defining and auditing quality standards andoutcomes.

Each of these themes will now be briefly discussedalong with any problems in delivering them.



High quality care was defined by one interviewee asthe provision of “the most appropriate treatment atthe most appropriate time by the most appropriateperson.” To ensure this, interviewees said that it is essential to have in place a service that usesresources efficiently while providing timely access todiagnosis and treatment for all. A number of optionsto achieve this were mentioned:

• standardised referral pathways with a single pointof entry

• clear communication between GP and breast unit

• access to same breast cancer surgery servicesregardless of geographical location

• identification of inappropriate referrals

A number of barriers to realising these options werementioned.

• Lack of management support; the uptake ofbreast reconstruction is not covered by an explicitnational target.

• Impact of current national cancer waiting timestargets; these targets aim to ensure the definitivetreatment of all symptomatic breast cancerpatients within 62 days from initial referral; in anattempt to meet these targets, surgeons maydiscourage patients who wish to opt forimmediate breast reconstruction at the time oftheir mastectomy.

• “Haphazard” follow-up arrangements; as a result,patients may lose contact with their surgeon andbreast cancer nurse when they are referred to theoncology team; problems may also arise forpatients when they need to access specialistservices for wound, lymphoedema and prosthesisproblems during adjuvant therapy.

Resources

Interviewees mentioned three aspects of the servicesthat are strongly dependent on the availableresources.

• Facilities; interviewees highlighted the importanceof a patient friendly out-patient clinicalenvironment that ensures patients’ dignity and

privacy as well as the availability of theatre andbed capacity to provide a full reconstructiveservice.

• Staffing; the need to have a team that includes allspecialties involved in breast cancer care(radiologists, pathologists, oncologists, breast carenurses, breast surgeons, reconstructive surgeons,physiotherapists); after discharge, easy access towound, prosthesis, lymphoedema and counsellingservices was seen as essential.

• Availability of reconstruction; intervieweesindicated that “a full repertoire of reconstruction”should be available to all patients.

It was felt that “not enough money” is madeavailable for breast reconstruction and that manyproviders “just wouldn’t have the resources” to offerall women a breast reconstruction. Most clinicianswho felt they did not have major problems with theircurrent rate of reconstruction indicated that theywould struggle to meet an increased demand. It wasalso indicated that the current funding climate madeit unlikely that Trusts would opt to do “lots ofcomplicated surgery which takes more time, is moreexpensive and will not help to meet the targets.”

Interviewees said that reductions in staff as well asproblems with recruiting experienced staff can makeit difficult to build up a complete multi-disciplinaryteam (MDT). As a result, some specialists are notalways available locally. This may impact on thetreatment that is available to women. For example,some MDTs do not include a surgeon withknowledge of the reconstructive options availableand as a result those MDTs might more oftenrecommend breast conserving surgery, particularly inwomen with relatively large or high grade tumours.

It was claimed that commissioners introduce barriersto the availability of reconstruction. For example,some Primary Care Trusts fund reconstruction butrefuse to fund surgery to the other breast requiredto obtain symmetry. Other Primary Care Trustsrequire a formal psychological assessment beforebreast reconstruction, a standard that somehospitals find difficulty in meeting.



The interviewees felt that providing patients withappropriate and sufficiently detailed informationabout breast cancer surgery is essential to highquality care. This involves access to completeinformation about the diagnosis, managementoptions, prognosis and outcomes.

Interviewees said that it is also important:

• to create an environment in which patients feelthat “they can raise emotional problems andconcerns without feeling silly or downtrodden”

• to make sure that family and care givers areincluded in the discussion about the treatmentoptions

• to make photographs available of the outcomesthat are obtained with the different treatments

• to offer women the chance to talk to others whohave undergone the surgery

• to inform patients about peer and charity supportgroups that can offer emotional and psychologicalsupport.

The patients who were interviewed mentioned anumber of problems.

• The poor quality of the provided information; onepatient said that she “could find better information[on the internet] than from the actual service.”

• Not enough information was provided early in thetreatment when it can help patients to makechoices about their treatment.

• Breast reconstruction is sometimes offered in adiscouraging way. This was described as“manipulation of vulnerable patients at the timeof their cancer diagnosis” by one of theinterviewed surgeons.


Many interviewees felt that informed choices aboutbreast reconstruction are not possible without timefor patients to obtain, digest and discuss informationrelevant to their care and decision making. Whiletimely care is important, patients need time to askquestions and avoid making complex decisionswithout sufficient information.

It was felt by some interviewees that best care “isn’tnecessarily best served by single consultations” andpatients should be allowed to discuss their treatment“at the first, the second and the third consultation.”This would ensure that a patient’s treatment choiceis “not just a knee jerk reaction but something theycan live with at the end.”

Interviewees felt that he national target requiring allwomen referred with symptoms of breast cancer toreceive definitive treatment within 62 days of initialreferral is the main barrier to allowing patientssufficient time to make a decision about theirtreatment. They said that it was often difficult toschedule out-patient appointments to allow apatient to have a full discussion regarding hertreatment options with a surgeon or breast carenurse. It was suggested that this may be one of themost significant factors preventing the uptake ofimmediate breast reconstruction by women inEngland and Wales.

Training of staff

Many interviewees mentioned the importance of:

• the quality of the training of the surgeons whoprovide breast reconstruction

• the training for breast cancer nurses given theirrole as patient advocates and “reconstructivegatekeepers.”

The surgical interviewees said that “improvingtraining of (reconstructive surgeons) and the qualityof those entering the specialty” are essential inensuring the quality of breast cancer surgery. Theyalso said that surgeons performing breastreconstruction surgery should be properly trainedand accredited.

Surgical interviewees claimed that many breastsurgeons rely on their plastic surgery colleagues forthe provision of reconstructive expertise. Althoughthis “two team” approach was thought to workextremely well in many cases, this lack of trainingand expertise on the breast surgeon’s part couldmake them more likely to “not want to referpatients who they can’t perform surgery onthemselves.”


A breast surgeon felt that these problems were adirect result of training issues and that “a hugeamount has to be done in training (breast)oncoplastic surgeons in aesthetic breasttechniques.” As a consequence, “too few plasticsurgeons are too stretched doing too much, as Ithink plastic surgery specialists don’t like to go downthe breast route.” Problems with trainingreconstructive surgeons were said to have led to aworkforce that is not completely skilled inreconstruction post-mastectomy.

Finally, interviewees reported their perception ofhuge differences in terms of the training, activity,and accessibility of breast care nurses. It was claimedthat these differences lead to significant variations inthe quality of care and support provided to womenwith breast cancer.


All clinical interviewees felt that the presence of aneffective MDT helps to ensure high quality patientcare. They felt that it is vital to ensure access to the“skills and quality of the multi-disciplinary team –diagnostic, decision making, cohesion, operative andcommunication.”

Patients reported their concerns with thecommunication between clinicians of differentdisciplines. This was thought to have a negativeeffect particularly on referrals from primary care tobreast units. In addition, concerns with referrals fromsurgical to oncology departments were mentionedas well as with those made to other providers iftreatments were not available locally.

A number of clinicians pointed explicitly towardsproblems in communication between surgeons.They identified problems such as a reluctance torefer out of the unit, antipathy between teams,breast surgeons not wanting to refer patients thatthey can not perform surgery on themselves, andproblems with communication between breast andplastic surgeons.


Interviewees highlighted the importance ofidentifying key standards of practice and care, and

then auditing current practice against thesestandards.

It was felt that all NHS Trust and private hospitalsshould be “explicit in the information (provided) andable to produce figures of outcomes.” Identifyingkey outcome measures following mastectomy andbreast reconstruction surgery was seen as the onlyway to measure the efficacy and quality of careprovided. Without knowing the outcomes ofsuccessful treatment and rehabilitation, it is notpossible to measure the quality of care or provide abenchmark for the future.

Interviewees identified two main problems inauditing breast cancer surgery practices andoutcomes:

• a lack of high quality evidence; as a consequence,it is impossible to develop meaningful nationalstandards of process or outcomes

• the difficulty in identifying measures that trulyreflect the quality of care provided.


7.0 The provision of breast cancer surgery services in England and Wales: An organisational surveyA survey was undertaken to identify the location andcharacteristics of the organisations involved inproviding breast cancer surgery. The objectives ofthe survey were:

• to identify centres carrying out mastectomy andbreast reconstruction surgery

• to specify multi-disciplinary team composition,number of breast care nurses, and bed capacity ateach centre

• to establish the types of mastectomy, breastreconstruction procedures, and chemotherapycarried out at each centre.

The information gathered will be used:

• to identify the population of centres carrying outvarious forms of breast cancer surgery in Englandand Wales

• to provide data on centre level characteristics thatmay be used to explain variation in patient leveloutcomes.

A list of all organisations (NHS Trusts and privatehospitals) involved in breast cancer surgery wasprepared from a wide range of sources. All NHSTrusts and private hospitals not on this list werecontacted to make sure that no provider was missed.Questionnaires were posted to named contacts atevery Trust/private hospital thought to beperforming mastectomy or breast reconstructionsurgery in England and Wales in 2007. Thesecontacts included all breast cancer lead clinicians atNHS Trusts and, for the 42 NHS Trusts which containa plastic surgery unit, the plastic surgery clinicaldirectors. The primary contact in the private sectorwas the hospital chief executive. Reminders (written,e-mail and by telephone) continued (to a secondarycontact if necessary) until an acceptable responserate was obtained.

Of the 155 NHS breast cancer lead clinicianscontacted, 140 (90 per cent) returned completedquestionnaires, as did all 42 (100 per cent) of theNHS plastic surgery clinical directors. As a result,completed questionnaires responses were obtainedfrom 144 (93 per cent) NHS Trusts providing

mastectomy or breast reconstruction. Of the 163chief executives of private hospitals who werecontacted, 143 (88 per cent) returned a completedquestionnaire.

Of the 144 Trusts that returned a questionnaire, 102(71 per cent) do not house a plastic surgery unit, 40(28 per cent) contain a plastic surgery unit workingalongside general surgeons with a sub-specialtyinterest in breast surgery, and two (one per cent)were Trusts where breast cancer surgery isperformed exclusively by plastic surgeons.

The results of the organisational survey are shown inFigure 1. Some respondents did not complete allitems on the questionnaire. The levels of missingdata are shown in the figure, and where proportionsare given in the text below, missing data has beenexcluded.

Reserved beds for breast cancer surgerypatients

Only 50 (35 per cent) of the NHS Trusts surveyedreported that they have reserved beds for breastcancer surgery patients. Of the 102 NHS Trustswithout a plastic surgery unit, 29 (29 per cent) havereserved breast cancer/breast reconstruction beds.This compares with 21 (52 per cent) of the 40 Trustswith both breast and plastics units, and neither ofthe two Trusts with isolated plastic surgery units.Only four (3 per cent) of the 143 private hospitalshave reserved beds for breast cancer surgicalpatients.

Consultants with a specialist interest in breastcancer diagnosis and treatment

Figure 1 demonstrates that almost all NHS Trusts orprivate hospitals employ a consultant breastsurgeon. However, a consultant plastic surgeon withan interest in breast cancer treatment is employedonly by about half of the NHS Trusts and about threequarters of the private hospitals. Figure 1 alsodemonstrates that a number of NHS Trusts do nothave a consultant oncologist, pathologist orradiologist with a specialist interest in breast canceremployed within the Trust. The absence of thesespecialists in private hospitals is higher.



Figure 1: Results of organisational survey of NHS Trusts and private hospitals in England and Wales thatperform breast cancer surgery.

Question NHS Trusts Private Hospitals(N = 144) (N = 143)

N (%) Missing (N) N (%) Missing (N)

Reserved beds for breast cancer surgery? 50 (35.5) 3 4 (2.9) 5

Consultants with a specialist interest in breast cancer?• Breast surgeon 142 (99.3) 1 141 (98.6) 0• Plastic surgeon 79 (56.0) 3 106 (74.1) 0• Oncologist 121 (87.7) 6 109 (76.2) 0• Pathologist 126 (92.0) 7 79 (55.2) 0• Radiologist 126 (91.3) 6 111 (77.6) 0

Dedicated breast care nurses? 136 (96.5) 3 125 (88.7) 2

Private hospitals patients discussed at - - 135 (95.1)outside MDT?

Pedicle flap reconstruction by 80 (56.3) 2 69 (48.6) 1breast surgeons?

Free flap reconstruction by 2 (1.4) 1 15 (10.6) 1breast surgeons?

Mastectomy procedures by 12 (8.5) 3 11 (7.7) 0plastic surgeons?

Carry out immediate reconstructions? 119 (84.4) 3 113 (83.1) 7

Carry out delayed reconstructions? 116 (83.5) 5 120 (93.0) 14

Mastectomies done for patients from 48 (34.0) 3 - -other Trusts?

Reconstructions done for patients from 50 (36.2) 6 - -other Trusts?

Chemotherapy use before surgery to enable immediate reconstruction?• High grade 97 (74.0) 13 108 (82.4) 12• Locally advanced 102 (77.9) 13 107 (82.3) 13• Metastatic 68 (55.3) 21 92 (72.4) 16

Compliance with NICE guidance? 128 (92.1) 5 118 (82.5) 0

Contribution to national datasets? 124 (89.9) 6 82 (60.7) 8

Dedicated breast care nurses

Breast care nurses play a central role in providinginformation to breast cancer surgery patients andsupporting them during the decision makingprocess. 136 (97 per cent) NHS Trusts and 125 (89per cent) private hospitals reported that they have adedicated breast care nurse. When present, NHSTrusts employ an average of three breast care nursesand private hospitals an average of 1.5 nurses. Seven(five per cent) NHS Trusts and 60 (43 per cent)private hospitals reported that they employ only onebreast care nurse.

MDT access in the private sector

135 (95 per cent) private hospitals reported that theneeds of their breast cancer surgery patients arediscussed at an MDT elsewhere.

Types of mastectomy and breast reconstructionsurgery performed

There is evidence that traditional surgical specialtyboundaries are breaking down, particularly within theprivate sector. It is now relatively common for generalsurgeons with a specialist interest in breast surgery toperform pedicle flap procedures, with 80 (56 per cent)NHS Trusts and 69 (49 per cent) private hospitalsreporting such practices. At two (one per cent) NHSTrusts and 15 (11 per cent) private hospitals free-flapreconstruction procedures are performed by breastsurgeons while at 12 (eight per cent) NHS Trusts and11 (eight per cent) private hospitals mastectomies areperformed by plastic surgeons.

Immediate and delayed breast reconstruction

119 NHS Trusts (84 per cent) reported that theyperform immediate reconstruction and 116 (83 percent) said they perform delayed reconstruction. All 42Trusts with a plastic surgery unit carry out bothimmediate and delayed breast reconstruction. Of the102 NHS Trusts without plastic surgery units, 78 (79per cent) perform immediate reconstruction and 75(77 per cent) perform delayed reconstruction. 113 (83per cent) of the private hospitals reported that theyperform immediate reconstruction and 120 (93 percent) perform delayed reconstruction. Eighteen (13per cent) of the Trusts and seven (five per cent) of theprivate hospitals that perform mastectomies reportedthat they perform no breast reconstruction surgery.

Provision of mastectomy and reconstructionsurgery for other Trusts

Patients are sometimes referred to other NHS Trustsfor mastectomy and/or breast reconstruction. Thesurvey indicated that mastectomy operations areprovided for other Trusts’ patients by 48 (34 percent) of all NHS Trusts. Breast reconstruction issimilarly provided for others by 50 (36 per cent)Trusts. Of the 42 NHS Trusts with a plastic surgeryunit, 40 (95 per cent) provide reconstruction forpatients referred from other NHS Trusts. Thisinformation was not collected from private hospitalsas they are not involved in official NHS referralpathways for mastectomy and breast reconstruction.

The use of chemotherapy before surgery and itseffect on offers of immediate reconstruction

Chemotherapy before surgery is increasingly beingused to achieve loco-regional control in women withhigh grade (aggressive) tumours, locally advanced ormetastatic disease. This treatment aims to reducethe size and spread of the cancer and the extent ofsurgery required. After recovery, mastectomy andimmediate reconstruction may then be carried out.

Three quarters of NHS Trusts reported that theywould provide such chemotherapy to patients withhigh grade or locally advanced disease to enable theoffer of immediate reconstruction, but only half ofthe Trusts would do so in the case of metastaticdisease. Private centres appeared more willing toprovide such chemotherapy to all three groups.

Compliance with NICE guidance

NICE in their 2002 ‘Improving Outcomes in BreastCancer’ report made one key recommendation ofrelevance to breast reconstruction surgery.

“Reconstruction should be available at the initialsurgical operation. If this cannot be provided withinone month of diagnosis, women should be offered achoice between routine surgery with delayedreconstruction (if desired), or waiting longer forinitial surgery.” 5

In total, 128 (92 per cent) NHS Trusts and 118 (83per cent) private hospitals stated that they complywith the recommendation.


Contribution to national clinical datasets

Ninety per cent of NHS Trusts and 82 per cent ofprivate hospitals report that they contribute to one or more national clinical datasets for breastcancer. The most commonly named were the NHSBreast Screening Programme/Association of BreastSurgeons dataset and the Breast Cancer ClinicalOutcome Measures dataset.


8.0 Hospital Episode Statistics (HES) on the number of breast cancer operationsperformed in England, 1997-2006Breast reconstruction is a rapidly evolving field, withan increasing number of surgeons and Trustsperceived to be offering such procedures. It isunclear as to how these changes have affectedwomen’s access to immediate or delayedreconstruction. The objective of this work is toidentify trends in the number and type of operationsperformed on women with breast cancer and thenumber of Trusts and private hospitals at which theyare provided.

This data will provide data on the impact of recentnational guidance on:

• access to immediate reconstruction

• centre level volumes of breast reconstructionsurgery.

Analyses were performed using the HES database ofthe Department of Health in England. This databaserecords medical, demographic and administrativedata relating to all patients admitted to NationalHealth Service hospitals in England. It includesprivate patient admissions to NHS hospitals but notpatients treated within private hospitals.

Data were extracted from the HES database for1997-1998 to 2005-2006 for all female patientswith an International Classification of Diseases (tenthrevision) diagnostic code for malignant neoplasm ofthe breast (breast cancer). This data was thenanalysed using STATA 9.2 and Microsoft Excelstatistical analysis software to describe trends inbreast conserving, mastectomy, and immediate anddelayed reconstruction surgery. This includedchanges in the number of Trusts performing thistype of surgery and the number of cases performedat each Trust. The operations identified in thisanalysis include procedures performed for recurrentbreast cancer and breast cancer secondary toanother cancer as well as for primary breast cancer.

Number and relative proportion of differenttypes of breast cancer surgery

Figure 2 shows the number and relative proportionof breast cancer surgery procedures carried out forwomen in the NHS in England between 1997 and2006. The number of breast conserving operations(e.g. lumpectomy) performed annually increasedfrom 14,090 to 19,962. Over the same period, the


Figure 2: Hospital Episode Statistics information on trends in breast cancer surgery for women in England,1997-2006

Year Breast conserving Mastectomy Mastectomy Total numbersurgery (% of total) without immediate with immediate of breast cancer

reconstruction reconstruction operations(% of total) (% of total)

1997-98 14,090 (57.1) 9,802 (39.7) 792 (3.2) 24,684

1998-99 15,609 (57.2) 10,696 (39.2) 987 (3.6) 27,292

1999-00 16,146 (57.0) 11,066 (39.0) 1128 (4.0) 28,340

2000-01 15,926 (56.5) 11,025 (39.1) 1246 (4.4) 28,197

2001-02 16,150 (56.0) 11,417 (39.6) 1248 (4.3) 28,815

2002-03 17,029 (56.9) 11,604 (38.8) 1303 (4.4) 29,936

2003-04 18,258 (57.6) 12,044 (38.0) 1369 (4.3) 31,671

2004-05 18,607 (58.1) 12,088 (37.7) 1355 (4.2) 32,050

2005-06 19,962 (59.0) 12,291 (36.3) 1561 (4.6) 33,814

number of mastectomy operations increased from9,802 to 12,291, and the number of immediatereconstruction procedures from 792 to 1,561. Thesechanges are consistent with the significant increasein breast cancer incidence over recent years.Although the overall number of operationsincreased, the relative proportions remainedremarkably stable. The likelihood of a woman withbreast cancer undergoing breast conserving surgery,mastectomy, or mastectomy with immediatereconstruction hardly changed over the nine yearperiod. As a proportion of all women undergoingmastectomy, the number undergoing mastectomywith immediate reconstruction has increased from 7per cent in 1997-1998 to 11 per cent in 2005-2006.

Delayed reconstruction surgery

Some of the women classified as ‘mastectomywithout immediate reconstruction’ below will havegone on to have a delayed reconstruction of theirbreast. Accurate identification of delayedreconstruction procedures is difficult within HES asone can only work forward from a confirmedmastectomy. For mastectomies performed in recentyears HES will produce an underestimate of delayedreconstruction procedures as women may have suchprocedures up to 20 years after their original

mastectomy. The most accurate estimate obtainablerelates to women who had a delayed reconstructionin 2005-2006 as nine years worth of HES data canbe used to identify their original mastectomyprocedure. Using this method it can be estimatedthat around 1,000 delayed reconstructions wereperformed in the NHS in England in 2005-2006. Thisis likely to be an underestimate as:

(i) some women who had a mastectomy prior to1997 will have had a delayed reconstruction in2005-2006 and it is not possible to identify thesewomen within HES

(ii) some women who had their original mastectomyoutside the English NHS (e.g. in another countryor in the private sector) will also have a delayedreconstruction in 2005-2006.

Centralisation of breast cancer surgery

Figure 3 shows the number of NHS Trusts in Englandthat performed breast cancer surgery over the period 1997 to 2006. The number of Trustsproviding breast conserving and mastectomy surgeryfell by 27 per cent, but the number providingimmediate reconstruction did not change. The largenumber of NHS Trust mergers that took place overthis period may mean that the degree of


Figure 3: Hospital Episode Statistics information on the number of NHS Trusts in England providing breastcancer surgery for women, 1997 to 2006.

Year Trusts performing Trusts performing Trusts performing Trusts performingbreast conserving mastectomy immediate delayedsurgery reconstruction reconstruction*

1997-98 211 209 114 -

1998-99 202 197 115 -

1999-00 187 183 118 -

2000-01 180 178 111 -

2001-02 169 171 116 -

2002-03 156 157 106 -

2003-04 155 151 110 -

2004-05 153 152 109 -

2005-06 154 153 114 174

*Best estimate available only for 2005-06, may be a slight underestimate

centralisation that took place at hospital level issomewhat overstated in Figure 3.

In 2005-2006, more Trusts perform delayed breastreconstruction than any other type of breast cancersurgery. As it is undertaken after the initial cancertreatment is complete, delayed breast reconstructioncan be performed without the involvement of abreast cancer MDT. This may explain why suchsurgery is available at a larger number of Trusts thanother types of breast cancer surgery.

Number of breast reconstruction proceduresperformed at each NHS Trust

The service changes recommended within the 2000NHS Cancer Plan aimed to ensure that patients werenot treated in “low volume” Trusts for their breastcancer6. This is reflected in national standards set forthe minimum number of cases diagnosed andtreated by an accredited breast unit annually. Thesenational standards do not currently extend to breastreconstruction, although the 2007 oncoplasticbreast surgery guidelines produced by the relevantUK surgical specialty associations state that acaseload of at least 25 major reconstructiveprocedures per annum should be performed in orderto qualify as an oncoplastic training unit.4 In 2005-2006, 180 NHS Trusts provided immediate and/ordelayed breast reconstruction procedures forwomen with a previous breast cancer diagnosis. Inthat year, 54 (30 per cent) of these Trusts performedless than six reconstructions. Ninety two Trusts (51per cent) performed between 6 and 24 procedureswith only 34 Trusts (19 per cent) undertaking 25 ormore procedures.

Trusts performing mastectomy but notimmediate breast reconstruction

The proportion of Trusts that performed mastectomysurgery but not immediate reconstruction fell from95 out of 209 (46 per cent) to 39 out of 153 (26 percent) between 1997 and 2006. Interestingly, 36 ofthe 39 NHS Trusts that provided mastectomy but notimmediate reconstruction in 2005-2006 were ableto provide delayed breast reconstruction.

Accuracy of HES

The above analysis assumes no systematic error inHES coding of breast cancer diagnosis and surgery.The prospective audit module of the NationalMastectomy and Breast Reconstruction Audit will tosome extent allow validation of HES as it will bepossible to compare HES data for 2008 with clinicaldata collected prospectively over the same period.


9.0 Discussion

The work carried out so far has demonstrated thatalthough there is a general perception that a goodsurgical service is available to women with breastcancer in England and Wales, there are considerablepressures upon the service. There are many sourcesof pressure.

• The rising incidence of breast cancer and the needto perform more operations.

• The requirement to provide a higher proportion ofwomen with reconstructive options aftermastectomy.

• The pressure created by cancer waiting timetargets, specifically the need to perform definitivetreatment within 62 days of initial referral.

• The pressure to centralise and perform surgery athigh volume centres.

• The difficulty securing resources to adequatelystaff an MDT, provide breast reconstructionprocedures and ring-fence beds, theatre time andstaff.

Service providers have coped admirably in the face ofthese pressures, providing a 37 per cent increase inthe number of operations performed over the period1997 to 2006. The overall number of immediatereconstruction procedures provided by the EnglishNHS almost doubled between 1997 and 2006.However, there seems to have been difficulty in implementing the 2002 NICE guidance thatimmediate reconstruction should be available for allwomen undergoing mastectomy. The proportion ofall women undergoing mastectomy who received animmediate reconstruction increased only from 7 percent to 11 per cent.

There was a significant consensus amongstakeholders about the determinants of quality inbreast cancer surgery. Seven themes were identified.

• Service configuration.

• Resources.

• Communication with patients.

• Time to allow informed and reasoned decisionmaking.

• Training of staff.

• Communication between clinicians.

• Defining and auditing quality standards andoutcomes.

These themes correspond to previous nationalguidance including the 2000 NHS Cancer Plan, the2002 NICE guidance ‘Improving Outcomes in BreastCancer,’ the 2007 Cancer Reform Strategy7 and the2007 oncoplastic surgery guidelines from the UKsurgical specialty associations. This implies aconsensus among stakeholders in breast cancersurgery which is an excellent basis on which to moveforward with service improvement. It is useful toconsider the evidence gathered on challenges toquality of care within each theme.


Local access to immediate breast reconstruction isnot uniform across England and Wales. Althoughfalling in number, 39 English NHS Trusts (26 percent) that performed mastectomy surgery in 2005-06 did not also provide immediate reconstruction asa local option according to HES. Even if these centreshave formal referral arrangements with othercentres, this extra step in the referral process maydeter some women from having a breastreconstruction. When directly asked, 92 per cent ofNHS Trusts and 82 per cent of private hospitalsreport that they comply with the 2002 NICEguidance on access to immediate reconstruction.However, it is not clear whether this refers tooffering the option of immediate reconstruction toall women undergoing mastectomy, or to facilitatingdelayed reconstruction instead.

In 2005-2006, 36 NHS Trusts performed delayedbreast reconstruction procedures but no immediatereconstructions. Breast reconstruction surgery,whether immediate or delayed, requires specialistsurgical skills along with the ward based supportrequired to ensure appropriate post-operative care2

so there is no obvious clinical reason to not provideimmediate breast reconstruction at a centre wheredelayed reconstruction is available.

There was also considerable variation in both theNHS and private sector with respect to the use ofchemotherapy before surgery to enable the offer ofan immediate reconstruction. 55 per cent of NHS


Trusts would provide the option of such therapy to a woman with metastatic disease while 45 per cent would not. 72 per cent of private hospitals said they would provide this option to women with metastatic disease. The variation observed islikely to create inequities in access to immediatebreast reconstruction.

Resources

Breast reconstruction surgery is resource-intensiveand the current funding climate within the NHScreates disincentives to increase the number ofprocedures performed. Indeed, there is a perceptionthat some service commissioners deliberately createbarriers to the availability of breast reconstructionsuch as insisting on a psychological evaluation. Oneway in which breast cancer centres have respondedto the pressure on their resources is by ring fencingbeds. To reduce the likelihood of surgery beingcancelled many Trusts now “ring fence” beds forwomen undergoing breast cancer surgery. Thismeans that emergency patients or those admitted byother specialties may not use these beds, as they arereserved exclusively for women undergoingmastectomy or breast reconstruction. An addedadvantage of having reserved beds is that the ward-based team looking after these patients becomeexpert in their care.


A national standard from the 2002 NICE report‘Improving Outcomes in Breast Cancer’ is thatspecialist breast care nurses should be available to allpatients with breast cancer, and involved as a coremember of any breast cancer multi-disciplinaryteam. These nurses play a central role in providinginformation to breast cancer surgery patients andsupporting them during the decision makingprocess. They provide a key support for patients whoare making decisions about breast reconstruction. Itis surprising to find that 11 per cent of privatehospitals providing breast cancer surgery do notmeet this standard.

NHS Trusts have on average twice as many breastcare nurses as private hospitals, reflecting the numberof patients seen by each. However, even taking into account patient numbers, it is undesirable thatsome centres employ only one breast care nurse.

This means that patients may be unable to accessspecialist nursing care if the sole nurse is away onannual or sick leave. Although only seven NHS Trustswith breast care nurses had only one such nurse, 60private hospitals reported this staffing level.


The decision to proceed with immediate breastreconstruction is difficult and women requireadequate time to digest the information and choicesavailable. The window of time available to make thisdecision is limited by the target laid down by the2000 NHS Cancer Plan that patients withsymptomatic breast cancer should receive theirdefinitive treatment within 62 days of referral. Thereis a perception that decisions about reconstructionare often relegated to a secondary concern becauseof the urgent need to move the patient to definitivetreatment within the 62 day window.

Training of staff

The training provided to surgeons who performmastectomy and breast reconstruction surgery is akey determinant of service quality. Ideally, breastsurgeons should receive their training at designatedoncoplastic training units which perform a relativelyhigh number of procedures as low volume centresmay provide a poor environment for surgeons totrain and improve their breast reconstruction skills2.One third of all the English NHS Trusts thatperformed breast reconstruction surgery for womenperformed less than six such procedures in 2005-2006, indicating that reconstruction surgery is stillperformed at Trusts with relatively little experience inthe field. Published guidance states that a minimumof 25 breast reconstruction procedures should beperformed per annum for a centre to qualify as anoncoplastic training unit.2 The 2007 Cancer Reformstrategy also states that:

“In some places consultants are continuing tooperate on very small numbers of cases… PCTsshould not commission services from providers withsuch low volumes.” (page 101)7

One encouraging development in the field ofsurgical training is the breakdown in surgicalspecialty boundaries as evidenced, for example, by


the 80 NHS Trusts who report that general surgeonswith a specialty interest in breast surgery performpedicle flap breast reconstructions. The innovativeoncoplastic breast training programme establishedby the British Association of Plastic Reconstructiveand Aesthetic Surgeons and the British Associationof Surgical Oncology may have encouraged thisdevelopment.


A fifth of the NHS Trusts that perform breast cancersurgery do not have a consultant oncologist,pathologist or radiologist with a specialist interest inbreast cancer within the Trust. This may impair thequality of diagnostic services and adjuvant (non-surgical) therapy planning for women treated atthese centres. The absence of oncologists at MDTmeetings may lead to difficulties identifying patientswho need adjuvant radiotherapy after mastectomy,making it difficult to decide whether patients are suitable for immediate breast reconstruction. In this situation, centres may choose to deferreconstruction in all women until the finalhistological (pathology) diagnosis is available. It istrue that many Trusts are visited by specialist breastoncologists employed elsewhere but this may stilllead to delays in decision making.

94 per cent of private hospitals report that the needsof their breast cancer surgery patients are discussedat a MDT elsewhere. This may impair the quality and speed of decision making about breastreconstruction for these patients and inhibit localefforts to audit the quality of care.


Most NHS Trusts and private hospitals contribute toone or more national clinical datasets on breastcancer care. However, most of these datasetscontain only limited information on breastreconstruction practices and outcomes. Theprospective data collection module of the National Mastectomy and Breast ReconstructionAudit aims to deal with this information deficit and all relevant service providers are stronglyencouraged to participate.


10.0 Conclusions

In general, there is a perception that breast cancersurgery services in England and Wales provide agood standard of care in difficult and demandingcircumstances. The rising incidence of breast cancerhas created a greatly increased demand for all formsof breast cancer surgery and service providers haveresponded well to this demand. Yet concerns withrespect to certain aspects of the service remain. The most important issue identified is inequity ofaccess for women who want an immediatereconstruction. Despite guidance from NICE in 2002that all women undergoing a mastectomy shouldhave this option there has been limited progress todate. A number of barriers must be overcome beforefull implementation of the NICE guidance is possible.

A prospective audit of women undergoingmastectomy with and without reconstruction inEngland and Wales began on the 1 January 2008,and will continue until the 30 September 2008. Thiscohort of women will then be followed up at threeand eighteen months using patient questionnairesthat will assess their satisfaction with care and thequality of life outcomes attained, while gatheringadditional data on treatments and complicationsfollowing the primary surgery. This will allow an in-depth patient level exploration of determinants ofaccess to immediate breast reconstruction.

The results presented in this first annual report haveinformed both the clinical dataset and patientquestionnaires to be used in the prospective audit,particularly with respect to information on thepersonal, clinical and organisational determinants ofaccess to immediate reconstruction. Future annualreports will provide progressively greater informationon this issue.


Appendix 1Prospective Data Collection Data Sheets


Appendix 2Organisational Representatives

National Mastectomy and BreastReconstruction Audit Project Board

• Martin Old, Project Board Executive, The NHS Information Centre

• Jan van der Meulen, Senior Supplier, CEU at RCS

• Steve Dean, Senior Supplier, CEU at RCS

• Hugh Bishop, Senior User, ABS at BASO

• Venkat Ramakrishnan, Senior User, BAPRAS

• Helen Laing, Commissioner, Healthcare Commission

National Mastectomy and BreastReconstruction Audit Clinical Reference Group

• Dick Rainsbury – Chair

• Tracy Philip and Sneh Khemka – Independent Hospitals

• Chris Holcombe – ABS at BASO

• Eva Weiler-Mithoff and Elaine Sassoon – BAPRAS

• Maria Noblet – RCN

• Kate Jones and Helen Mcleod - Chartered Societyof Physiotherapy

• Dr Janet Litherland - Royal College of Radiologists

• Peter J Venn - The Royal Society of Anaesthetists

• Emma Pennary and Hannah Saul – Cancer Charities

• Lucy Elliss-Brookes – Cancer Networks

• Di Riley – Cancer Action Team

• Gill Lawrence - Cancer Registries

• Ian Monypenny – Wales

• Gillian Ross – Clinical Oncologist


Appendix 3Contributing Organisations

The following organisations provided a response tothe organisational audit. Only responses receivedbefore the deadline have been included in theanalysis. Some units have reorganised since replyingto the organisational questionnaire. The names givenat the time of response have been used in this report.

NHS TRUSTS

AINTREE HOSPITALS NHS TRUST

AIREDALE NHS TRUST

ASHFORD AND ST PETER'S HOSPITALS NHS TRUST

BARKING, HAVERING AND REDBRIDGE HOSPITALNHS TRUST

BARNET AND CHASE FARM HOSPITALS NHS TRUST

BARNSLEY HOSPITAL NHS FOUNDATION TRUST

BARTS AND THE LONDON NHS TRUST

BASILDON AND THURROCK UNI HOSP NHSFOUNDATION TRUST

BEDFORD HOSPITAL NHS TRUST

BLACKPOOL, FYLDE AND WYRE HOSPITALS NHS TRUST

BOLTON HOSPITALS NHS TRUST

BRADFORD TEACHING HOSPITALS NHSFOUNDATION TRUST

BRIGHTON AND SUSSEX UNIVERSITY HOSPITALS NHS TRUST

BRO MORGANNWG NHS TRUST

BROMLEY HOSPITALS NHS TRUST

BUCKINGHAMSHIRE HOSPITALS NHS TRUST

BURTON HOSPITALS NHS TRUST

CAMBRIDGE UNIVERSITY HOSPITALS NHSFOUNDATION TRUST

CARDIFF AND VALE NHS TRUST

CARMARTHENSHIRE NHS TRUST

CEREDIGION AND MID WALES NHS TRUST

CHELSEA AND WESTMINSTER HEALTHCARE NHS TRUST

CHESTERFIELD ROYAL HOSPITAL NHSFOUNDATION TRUST

CITY HOSPITALS SUNDERLAND NHS FOUNDATION TRUST

CLATTERBRIDGE CENTRE FOR ONCOLOGY NHS TRUST

CONWY AND DENBEIGHSHIRE NHS TRUST

COUNTESS OF CHESTER HOSPITAL NHSFOUNDATION TRUST

COUNTY DURHAM AND DARLINGTON ACUTEHOSP NHS TRUST

DARTFORD AND GRAVESHAM NHS TRUST

DONCASTER AND BASSETLAW HOSP NHSFOUNDATION TRUST

DUDLEY GROUP OF HOSPITALS NHS TRUST

EAST AND NORTH HERTFORDSHIRE NHS TRUST

EAST CHESHIRE NHS TRUST

EAST LANCASHIRE HOSPITALS NHS TRUST

EAST SUSSEX HOSPITALS NHS TRUST

ESSEX RIVERS HEALTHCARE NHS TRUST

FRIMLEY PARK HOSPITAL NHS FOUNDATION TRUST

GATESHEAD HEALTH NHS FOUNDATION TRUST

GEORGE ELIOT HOSPITAL NHS TRUST

GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST

GOOD HOPE HOSPITAL NHS TRUST

GUY'S AND ST THOMAS' NHS FOUNDATION TRUST

GWENT HEALTHCARE NHS TRUST

HEATHERWOOD AND WEXHAM PARK HOSPITALS NHS TRUST

HEREFORD HOSPITALS NHS TRUST

HINCHINGBROOKE HEALTH CARE NHS TRUST

HOMERTON UNIVERSITY HOSPITAL NHSFOUNDATION TRUST

HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST

IMPERIAL COLLEGE HEALTHCARE NHS TRUST

ISLE OF WIGHT HEALTHCARE NHS TRUST



JAMES PAGET HEALTHCARE NHS TRUST

KETTERING GENERAL HOSPITAL NHS TRUST

KING'S COLLEGE HOSPITAL NHS TRUST

KINGSTON HOSPITAL NHS TRUST

LANCASHIRE TEACHING HOSPITALS NHSFOUNDATION TRUST

LEEDS TEACHING HOSPITALS NHS TRUST

LUTON AND DUNSTABLE HOSPITAL NHS TRUST

MAIDSTONE AND TUNBRIDGE WELLS NHS TRUST

MAYDAY HEALTHCARE NHS TRUST

MID ESSEX HOSPITAL SERVICES NHS TRUST

MID STAFFORDSHIRE GENERAL HOSPITALS NHSTRUST

MID YORKSHIRE HOSPITALS NHS TRUST

MILTON KEYNES GENERAL HOSPITAL NHS TRUST

NORFOLK AND NORWICH UNIVERSITY HOSPITALNHS TRUST

NORTH BRISTOL NHS TRUST

NORTH CHESHIRE HOSPITALS NHS TRUST

NORTH CUMBRIA ACUTE HOSPITALS NHS TRUST

NORTH EAST WALES NHS TRUST

NORTH GLAMORGAN NHS TRUST

NORTH HAMPSHIRE HOSPITALS NHS TRUST

NORTH MIDDLESEX UNIVERSITY HOSPITAL NHS TRUST

NORTH TEES AND HARTLEPOOL NHS TRUST

NORTH WEST WALES NHS TRUST

NORTHAMPTON GENERAL HOSPITAL NHS TRUST

NORTHERN DEVON HEALTHCARE NHS TRUST

NORTHERN LINCOLNSHIRE AND GOOLE NHSFOUNDATION TRUST

NORTHUMBRIA HEALTH CARE NHS TRUST

NOTTINGHAM CITY HOSPITAL NHS TRUST

OXFORD RADCLIFFE HOSPITALS NHS TRUST

PEMBROKESHIRE AND DERWEN NHS TRUST

PENNINE ACUTE HOSPITALS NHS TRUST

PETERBOROUGH AND STAMFORD NHSFOUNDATION TRUST

PLYMOUTH HOSPITALS NHS TRUST

PONTYPRIDD AND RHONDDA NHS TRUST

POOLE HOSPITAL NHS TRUST

PORTSMOUTH HOSPITALS NHS TRUST

QUEEN ELIZABETH HOSPITAL NHS TRUST

QUEEN MARY'S SIDCUP NHS TRUST

QUEEN VICTORIA HOSPITAL NHS FOUNDATIONTRUST

ROYAL BERKSHIRE AND BATTLE HOSPITALS NHS TRUST

ROYAL BOURNEMOUTH AND CHRISTCHURCH NHSFOUNDATION TRUST

ROYAL CORNWALL HOSPITALS NHS TRUST

ROYAL DEVON AND EXETER NHS FOUNDATION TRUST

ROYAL FREE HAMPSTEAD NHS TRUST

ROYAL LIVERPOOL AND BROADGREEN UNI HOSP NHS TRUST

ROYAL SURREY COUNTY HOSPITAL NHS TRUST

ROYAL UNITED HOSPITAL BATH NHS TRUST

ROYAL WEST SUSSEX NHS TRUST

SALISBURY FOUNDATION NHS TRUST

SANDWELL AND WEST BIRMINGHAM HOSPITALS NHS TRUST

SCARBOROUGH AND NORTH EAST YORKSHIRE NHS TRUST

SHEFFIELD TEACHING HOSPITALS NHSFOUNDATION TRUST

SHERWOOD FOREST HOSPITALS NHS TRUST

SOUTH DEVON HEALTH CARE NHS TRUST

SOUTH MANCHESTER UNIVERSITY HOSPITALS NHS TRUST

SOUTH TEES HOSPITALS NHS TRUST

SOUTH TYNESIDE NHS FOUNDATION TRUST



SOUTH WARWICKSHIRE GENERAL HOSPITALS NHS TRUST

SOUTHAMPTON UNIVERSITY HOSPITALS NHSTRUST

SOUTHEND HOSPITAL NHS TRUST

SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST

ST GEORGE'S HEALTHCARE NHS TRUST

ST HELENS AND KNOWSLEY HOSPITALS NHS TRUST

SURREY AND SUSSEX HEALTHCARE NHS TRUST

SWANSEA NHS TRUST

SWINDON AND MARLBOROUGH NHS TRUST

TAUNTON AND SOMERSET NHS TRUST

THE HILLINGDON HOSPITAL NHS TRUST

THE MID CHESHIRE HOSPITALS NHS TRUST

THE NEWCASTLE UPON TYNE HOSPITALS NHSTRUST

THE PRINCESS ALEXANDRA HOSPITAL NHS TRUST

THE QUEEN ELIZABETH HOSPITAL KING'S LYNN NHS TRUST

THE ROTHERHAM NHS FOUNDATION TRUST

THE ROYAL MARSDEN NHS FOUNDATION TRUST

THE ROYAL WOLVERHAMPTON HOSPITALS NHS TRUST

THE WHITTINGTON HOSPITAL NHS TRUST

TRAFFORD HEALTHCARE NHS TRUST

UNITED BRISTOL HEALTHCARE NHS TRUST

UNITED LINCOLNSHIRE HOSPITALS NHS TRUST

UNIVERSITY HOSPITAL BIRMINGHAM NHSFOUNDATION TRUST

UNIVERSITY HOSPITAL OF NORTH STAFFORDSHIRENHS TRUST

UNIVERSITY HOSPITALS COVENTRY ANDWARWICKSHIRE NHS

UNIVERSITY HOSPITALS OF LEICESTER NHS TRUST

UNIVERSITY HOSPITALS OF MORECAMBE BAY NHS TRUST

VELINDRE NHS TRUST

WALSALL HOSPITALS NHS TRUST

WEST DORSET GENERAL HOSPITALS NHS TRUST

WEST HERTFORDSHIRE HOSPITALS NHS TRUST

WEST MIDDLESEX UNIVERSITY HOSPITAL NHSTRUST

WEST SUFFOLK HOSPITALS NHS TRUST

WESTON AREA HEALTH NHS TRUST

WHIPPS CROSS UNIVERSITY HOSPITAL NHS TRUST

WINCHESTER AND EASTLEIGH HEALTHCARE NHSTRUST

WORCESTERSHIRE ACUTE HOSPITALS NHS TRUST

WORTHING AND SOUTHLANDS NHS HOSPSFOUNDATION TRUST

YEOVIL DISTRICT HOSPITAL NHS FOUNDATIONTRUST

YORK HOSPITALS NHS TRUST

INDEPENDENT ORGANISATIONS

ABBEY CALDEW HOSPITAL

ABBEY SEFTON HOSPITAL

BISHOPS WOOD HOSPITAL

BLACKHEATH HOSPITAL

BMI - BATH CLINIC

BMI - CHATSWORTH SUITE

BMI - CHELSFIELD PARK HOSPITAL

BMI - FAWKHAM MANOR HOSPITAL

BMI - GORING HALL HOSPITAL

BMI - MOUNT ALVERNIA HOSPITAL

BMI - SARUM ROAD HOSPITAL

BMI - THE ALEXANDRA HOSPITAL

BMI - THE BEARDWOOD HOSPITAL

BMI - THE CHAUCER HOSPITAL

BMI - THE CHILTERN HOSPITAL

BMI - THE CLEMENTINE CHURCHILL HOSPITAL

BMI - THE DROITWICH SPA HOSPITAL



BMI - THE ESPERANCE HOSPITAL

BMI - THE FOSCOTE HOSPITAL

BMI - THE GARDEN HOSPITAL

BMI - THE HAMPSHIRE CLINIC

BMI - THE HARBOUR HOSPITAL

BMI - THE HIGHFIELD HOSPITAL

BMI - THE KINGS OAK HOSPITAL

BMI - THE LONDON INDEPENDENT HOSPITAL

BMI - THE MANOR HOSPITAL

BMI - THE MERIDEN HOSPITAL

BMI - THE PARK HOSPITAL

BMI - THE PRINCESS MARGARET HOSPITAL

BMI - THE RIDGEWAY HOSPITAL

BMI - THE RUNNYMEDE HOSPITAL

BMI - THE SANDRINGHAM HOSPITAL

BMI - THE SHELBURNE HOSPITAL

BMI - THE SLOANE HOSPITAL

BMI - THE SOMERFIELD HOSPITAL

BMI - THE WINTERBOURNE HOSPITAL

BMI - THORNBURY HOSPITAL

BMI - THREE SHIRES HOSPITAL

BMI - WERNDALE HOSPITAL

BMI SOUTH CHESHIRE PRIVATE HOSPITAL (BUPA)

BUPA ALEXANDRA HOSPITAL

BUPA CAMBRIDGE LEA HOSPITAL

BUPA GATWICK PARK HOSPITAL

BUPA HARTSWOOD HOSPITAL

BUPA HOSPITAL BRISTOL

BUPA HOSPITAL BUSHEY

BUPA HOSPITAL CARDIFF

BUPA HOSPITAL HARPENDEN

BUPA HOSPITAL HASTINGS

BUPA HOSPITAL LEEDS

BUPA HOSPITAL LEICESTER

BUPA HOSPITAL LITTLE ASTON

BUPA HOSPITAL MANCHESTER

BUPA HOSPITAL NORWICH

BUPA HOSPITAL PORTSMOUTH

BUPA HOSPITAL TUNBRIDGE WELLS

BUPA HOSPITAL WASHINGTON

BUPA HOSPTIAL SOUTHAMPTON

BUPA MURRAYFIELD HOSPITAL

BUPA NORTH CHESHIRE HOSPITAL

BUPA PARKWAY HOSPITAL

BUPA REDWOOD DIAGNOSIS AND TREATMENT CENTRE

BUPA RODING HOSPITAL

BUPA SOUTH BANK HOSPITAL

BUPA WELLESLEY HOSPITAL

CAPIO ASHTEAD HOSPITAL

CAPIO FITZWILLIAM HOSPITAL

CAPIO FULWOOD HOSPITAL

CAPIO MOUNT STUART HOSPITAL

CAPIO NEW HALL HOSPITAL NHS TREATMENT CENTRE

CAPIO OAKLANDS HOSPITAL

CAPIO OAKS HOSPITAL

CAPIO PARK HILL HOSPITAL

CAPIO PINEHILL HOSPITAL

CAPIO RIVERS HOSPITAL

CAPIO SPRINGFIELD HOSPITAL

CAPIO WEST MIDLANDS HOSPITAL

CAPIO WINFIELD HOSPITAL

CAPIO WOODLAND HOSPITAL

CAPIO YORKSHIRE CLINIC

CLARE PARK HOSPITAL

CROMWELL HOSPITAL

DUCHY HOSPITAL



DUNEDIN HOSPITAL

EAST KENT MEDICAL SERVICES LTD

ELLAND HOSPITAL(BUPA)

EUXTON HALL HOSPITAL

FAIRFIELD HOSPITAL

FYLDE COAST NHS TREATMENT CENTRE

HOLLY HOUSE HOSPITAL

HOSPITAL OF ST JOHN AND ST ELIZABETH

HULL AND EAST RIDING HOSPITAL

KING EDWARD VII HOSPITAL

LONDON BRIDGE HOSPITAL

LOURDES HOSPITAL

METHLEY PARK HOSPITAL (BUPA)

NEW VICTORIA HOSPITAL

NUFFIELD HOSPITAL BIRMINGHAM

NUFFIELD HOSPITAL BOURNEMOUTH

NUFFIELD HOSPITAL BRENTWOOD

NUFFIELD HOSPITAL BRIGHTON

NUFFIELD HOSPITAL BURY ST EDMUNDS

NUFFIELD HOSPITAL CAMBRIDGE

NUFFIELD HOSPITAL CHELTENHAM

NUFFIELD HOSPITAL CHICHESTER

NUFFIELD HOSPITAL DERBY

NUFFIELD HOSPITAL EXETER

NUFFIELD HOSPITAL GROSVENOR (CHESTER)

NUFFIELD HOSPITAL GUILDFORD

NUFFIELD HOSPITAL HAMPSHIRE

NUFFIELD HOSPITAL HAYWARDS HEATH

NUFFIELD HOSPITAL HEREFORD (WYE VALLEY)

NUFFIELD HOSPITAL HUDDERSFIELD

NUFFIELD HOSPITAL HULL

NUFFIELD HOSPITAL IPSWICH

NUFFIELD HOSPITAL LINCOLN

NUFFIELD HOSPITAL NEWCASTLE-UPON-TYNE

NUFFIELD HOSPITAL NORTH LONDON (ENFIELD)

NUFFIELD HOSPITAL NORTH STAFFORDSHIRE

NUFFIELD HOSPITAL PLYMOUTH

NUFFIELD HOSPITAL SHREWSBURY

NUFFIELD HOSPITAL TAUNTON

NUFFIELD HOSPITAL TUNBRIDGE WELLS

NUFFIELD HOSPITAL WARWICK

NUFFIELD HOSPITAL WOKING

NUFFIELD HOSPITAL WOLVERHAMPTON

NUFFIELD HOSPITAL YORK

PARKSIDE HOSPITAL

ROWLEY HALL HOSPITAL

SHIRLEY OAKS HOSPITAL

ST ANTHONY’S HOSPITAL

ST HUGH'S HOSPITAL

ST JOSEPH’S PRIVATE HOSPITAL

ST SAVIOUR'S HOSPITAL

The Harley Street Clinic

The London Clinic

THE PORTLAND HOSPITAL FOR WOMEN AND CHILDREN

THE PRINCESS GRACE HOSPITAL

WOODBOURNE PRIORY (BIRMINGHAM)

WOODLANDS HOSPITAL


Glossary

ABS - The Association of Breast Surgery (ABS) is thespecialty society that represents breast cancersurgeons and is part of the British Association ofSurgical Oncology. It is one of the key stakeholdersleading the audit.

Adjuvant treatment - An additional therapy (e.g.chemotherapy, radiotherapy, hormone drug therapy)provided to improve the effectiveness of the primarytreatment (e.g. breast cancer surgery). This may aimto reduce the chance of local recurrence of the canceror to improve the patient’s overall chance of survival.

Autologous breast reconstruction - The reconstructionof the breast mound (or shape) using only the patient’sown tissue (without any prosthesis or implant).

Breast reconstruction surgery - The surgical recreationof the breast mound (or shape) after some or all ofthis has been lost or removed (e.g. after breast cancersurgery).

BAPRAS - The British Association of Plastic,Reconstructive and Aesthetic Surgeons is the specialtysociety that represents plastic surgeons. It is one of thekey stakeholders leading the audit.

BASO - The British Association of Surgical Oncology is aspecialty society that is comprised of the Association ofBreast Surgery and the Association of Cancer Surgery.

Chemotherapy - Drug therapy used to treat cancer. Itmay be used alone, or in conjunction with other typesof treatment (e.g. surgery or radiotherapy)

CRG - The audit’s Clinical Reference Group iscomprised of representatives of the key stakeholdersin breast cancer care. They advise the Project Team onparticular aspects of the project and provide inputfrom the wider clinical and patient community.

CEU - The Clinical Effectiveness Unit is an academiccollaboration between The Royal College of Surgeonsof England and the London School of Hygiene andtropical Medicine, and undertakes national surgicalaudit and research. It is one of the key stakeholdersleading the audit.

Delayed breast reconstruction - The reconstruction ofthe breast mound (or shape) after a mastectomy hasalready been performed. This is undertaken as aseparate operative procedure.

Free flap breast reconstruction - The breast mound (orshape) is reconstructed using the patient’s own tissue(e.g. skin, fat, muscle) from another part of the body(donor area). The tissue is completely detached fromthe donor area before it is moved, with microsurgeryused to rejoin its arteries and veins to those in thebreast area. This means that tissue can also be takenfrom areas not adjacent to the breast, such as thebuttock or thigh.

Healthcare Commission - The Healthcare Commissionis the independent watchdog for healthcare inEngland. They aim to promote improvement in theservices provided by the NHS and independenthealthcare organisations.

HES - Hospital Episode Statistics is a database whichcontains data on all in-patients treated within NHSTrusts in England. This includes details of admissions,diagnoses and those treatments undergone.

Immediate breast reconstruction - The reconstructionof the breast mound (or shape) at the same time asthe mastectomy, undertaken as part of the sameoperative procedure.

The NHS Information Centre - The NHS InformationCentre is a special health authority that provides factsand figures to help the NHS and social services runeffectively. The National Clinical Audit SupportProgramme (NCASP) is one of its key components.

Implant-only breast reconstruction - The breastmound (or shape) is reconstructed using a tissueexpander (the volume can be increased by injectingsaline through a port placed under the skin) or adefinitive implant (the volume is fixed). The expanderor implant is placed under the pectoral (chest) muscle.A tissue expander may be exchanged for a definitiveimplant or left in place after expansion.

Lumpectomy - A surgical procedure to remove adiscrete lump or abnormal area of tissue from thebreast.

Lymphoedema - Swelling due to the build up ofprotein-rich fluid in the tissues. In breast cancerpatients this occurs when the lymphatic drainagesystem that normally removes this fluid is damaged bysurgery or radiotherapy to the armpit. The swellingusually affects the arm on the treated side.


Glossary

Mammography - An imaging modality that uses x-raysto show abnormalities and structure of a breast.

Mastectomy - The removal of all breast tissue, usuallyperformed as a treatment for breast cancer. Variationsinvolve leaving some or all of the skin over the breast(skin-sparing) or removing some of the underlyingpectoral muscle as well (total).

Metastatic disease - When cancer has spread from theplace in which it started to other parts of the body

MDT - The breast cancer multi-disciplinary team is agroup of professionals from diverse specialties thatworks to optimise diagnosis and treatmentthroughout the patient pathway.

Cancer Registry - The Cancer Registries (Eight inEngland, and one each for Wales, Scotland andNorthern Ireland) collect, analyse and report data oncancers in their area, and submit a standard dataseton these registrations to the Office for NationalStatistics.

NCASP - The National Clinical Audit SupportProgramme is part of the NHS Information Centre forHealth and Social Care, and manages a number ofnational clinical audits in the areas of cancer, diabetesand heart disease. It is one of the key stakeholdersleading the audit.

Neo-adjuvant chemotherapy - Chemotherapy givenbefore another treatment, usually surgery. This isusually given to reduce the size, grade or stage of thecancer and therefore improve the effectiveness of thesurgery performed.

Neoplasm - A neoplasm or tumour is an abnormalmass of tissue that results when cells divide more thanthey should or do not die when they should.Neoplasms may be benign (not cancerous), ormalignant (cancerous).

NICE - The National Institute of Clinical Excellence isan independent organisation responsible for providingnational guidance on the promotion of good healthand the prevention and treatment of ill health.

ONS - The Office for National Statistics (ONS) is thegovernment department responsible for collectingand publishing official statistics about the UK’s societyand economy. This includes cancer registration data.

Pedicle flap breast reconstruction - The breast mound(or shape) is reconstructed by moving a ‘flap’ of skin,muscle and fat from the patient’s back or abdomen tothe breast area, while keeping intact a ‘pedicle’ ortube of tissue containing its supplying arteries andveins.

PEDW - Patient Episode Database Wales contains dataon all in-patients treated within NHS Trusts in Wales.This includes details of admissions, diagnoses andthose treatments undergone.

Peri-operative period - The time period surrounding apatient’s surgical procedure

Project Board - The audit’s Project Board consists ofsenior representatives of the key stakeholders and theHealthcare Commission, and acts to ensure that theaudit is meeting its contractual targets and objectives.

Project Team - The audit’s Project Team consists ofclinical, audit and management representatives of thekey stakeholders and works to design, implement,analyse and report on the audit.

RCN - The Royal College of Nursing is an independentprofessional body that represents nurses and nursing,promotes excellence in practice and shapes healthpolicies, and in particular aims to improve the qualityof patient care.

RCS - The Royal College of Surgeons of England is anindependent professional body committed toenabling surgeons to achieve and maintain thehighest standards of surgical practice and patientcare. As part of this it supports audit and theevaluation of clinical effectiveness for surgery.

STATA 9.2 - A statistical analysis software packageused in our analyses.

Tumour ablation - The destruction or removal of atumour using surgical or non-surgical methods.

Ultrasound - A imaging modality that uses highfrequency sound waves to create an image of tissuesor organs in the body.


References

1 Improving Outcomes in Breast Cancer – ManualUpdate, 2002. London: National Institute forClinical Excellence.

2 Oncoplastic breast surgery – a guide to goodpractice, 2007. The Association of Breast Surgeryat BASO and the British Association of Plastic,Reconstructive and Aesthetic Surgeons TrainingInterface Group in Breast Surgery. EuropeanJournal of Surgical Oncology 2007;33: S1-S23.

3 Office for National Statistics. Cancer StatisticsRegistrations: Registrations of Cancer Diagnosedin 2004, England. Series MB1 no.35, 2007.London: TSO.

4 Welsh Cancer Intelligence and Surveillance Unit.Cancer Incidence in Wales 2004, 2007. WelshCancer Intelligence and Surveillance Unit.

5 Office for National Statistics. Mortality Statistics:Cause. England and Wales 2005. London: TSO.

6 The NHS Cancer Plan, 2000. London: Departmentof Health.

7 Cancer Reform Strategy, 2007: London:Department of Health.


FOR HEALTH AND SOCIAL CARE

The NHS Information Centre is working tomake information more relevant andaccessible to the public, regulators, healthand social care professionals and policymakers, leading to improvements inknowledge and efficiency. The NHSInformation Centre is an NHS special healthauthority that collects, analyses anddistributes data to reduce the burden onfrontline staff, releasing more time for direct care.

This work remains the sole and exclusiveproperty of The NHS Information Centre andmay only be reproduced where there is explicitreference to the ownership of The NHSInformation Centre.

This work may be re-used by NHS andgovernment organisations without permission.Commercial re-use of this work must be grantedby The NHS Information Centre.

Copyright © 2008. The NHS Information Centre,National Mastectomy and Breast ReconstructionAudit All rights reserved.

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