ycn breast educational meeting 2015-nice breast cancer quality standards- e appleton, j naik
TRANSCRIPT
The NICE Breast Cancer Quality Standards - Are they helpful and how are we doing against them?E APPLETON, J NAIK
What are the breast cancer quality standards?
“This quality standard describes markers of high-quality, cost-effective care that, when delivered collectively, should contribute to improving the effectiveness, safety and experience of care for adults with breast cancer…”
Preventing people from dying prematurely.Enhancing quality of life for people with long-term conditions.Helping people to recover from episodes of ill health.Ensuring that people have a positive experience of care. Treating and caring for people in a safe environment and protecting them
from avoidable harm.
What are the breast cancer quality standards?
3: Breast Conserving
Surgery
1: Referral 5: Pathology – ER/HER2
Status8:
Adjuvant Therapy Planning
2: Clinical Assessment 7: Staging
10: Follow Up
Imaging
9: Clinical Follow Up
12: Key Worker
13: Brain Metastasis
11: MDT6:
Management
4: Mastectomy
How should we use them? Not intended as a set of targets or mandatory indicators for performance management Aim is to drive up standard of care i.e. target 100% (or 0% if a negative outcome) Provide an opportunity to -Evaluate the service as a whole – local +/- regionalEngage with the wider MDT Improve patient care Improve Peer Review measures
Challenges presented –Quantity of outcomes Clarity of some statements
How should we use them? Quantity -
13 outcomes, 12 protocols, ~ 36 outcomes/audits Who does what/when? Difficulty keeping track…
What was done Prior audit in Mid yorks (presented May 2014) – separate audits covering all the auditable quality standards Long and labour-intensive process (started in 2012) Aim was to devise a more efficient/focused method of re-auditing services. Audit tool -
◦ Focused on key areas identified from the previous audit◦ Attempted to facilitate easier data entry◦ Aim to standardise for future audits◦ Rolled out across the network (Responses from Leeds and Bradford)
Demographics/process 235 patients across 3 sites, diagnosed Sept-Dec 2014 (3 month period)
Data collection done by multiple team members (varied among trusts – 2 from Leeds, 1 from Brad and multiple from MY).
Data then analysed centrally, with some input from local teams when anomalies were encountered.
Leeds MY Brad
Female 79 Female 80 Female 73Male 1 Male 2 Male 070+ 29 70+ 33 70+ 18<70 51 <70 49 <70 55Total 80 Total 82 Total 73
Total YCN 235
Results - Radiology/clinical assessment
Did the patient receive a pre-
treatment USS of the axilla
If positive, did they receive a needle
biopsy (FNA/core)
If needle biopsy was negative, did
they receive a SNB
Did they undergo >1 axillary
operation eg SNB followed by ANC
“People with early invasive breast cancer are offered a pre-treatment ultrasound evaluation of the axilla and, if abnormal lymph nodes are identified, ultrasound-guided needle biopsy (fine needle aspiration or core). Those with no evidence of lymph node involvement on needle biopsy are offered sentinel lymph node biopsy when axillary surgery is performed”
Results - Radiology/clinical assessment
Pre Tx USS Needle Bx if +ve USS SNB if -ve Bx Patients undergoing >1 axillary operation
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Clinical assessment
Leeds MY Brad Cross site
Leeds MY Brad Cross site0
20
40
60
80
100
% FNA vs Core Bx
FNA Core
Results – Radiology/clinical assessment
Good! 231/235 patients received a pre treatment USS 98/100 patients with a positive USS received a needle biopsy 72/74 patients with negative needle biopsies received a SNB Only 23 patients underwent >1 axillary operation (11%)
All deviations explained by patient choice or condition. 1 patient had an MRI axilla over USS, 1 patient was unfit for further investigation following diagnosis, 1 developed a PE prior to SNB, and 1 had locally advanced disease confirmed on punch biopsy. Rates of re-operation low across the network. Majority FNA over core (80% vs 20%) Recommendation Continue current management
Results - Breast conserving surgery
“People with early breast cancer undergoing breast conserving surgery, which may include the use of oncoplastic techniques, have an operation that both minimises local recurrence and achieves a good aesthetic outcome.”
Did the patient undergo breast
conserving surgery
Was there a need for re-operation
Number of re-operations
Results - Breast conserving surgery
Leeds MY Brad Cross site0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
55%
39%
58%
50%
5%
15%21%
14%
Breast conserving surgery
Rate of BCS Rate of reoperation
Results – Breast conserving surgery
114/226 surgical candidates underwent BCS 16/114 had more than one operation, with a delay in definitive surgical management of 27-72 days (although one slightly anomalous at 224 days)
Lower BCS rates in MY over this period (prev 63% in 2012) ? Case review/review of data
Re-operation rates Very low in Leeds – can anything be learnt from this? Rest near/within the EUSOMA gold standard figure of 20% Significant decrease in MY (33% 15% from previous audit)
May be some variability due to interpretation by those collecting data – eg some said “Yes” to re-op, but annotated as a further axillary operation, or evacuation of a haematoma.
Recommendations More detailed audit to evaluate the trends/conclusions
Results - Pathology (ER and HER2 status)
Quality statement
“People with newly diagnosed invasive breast cancer and those with recurrent disease (if clinically appropriate) have the ER and HER2 status of the tumour assessed and the results made available within 2 weeks to allow planning of systemic treatment by the multidisciplinary team.”
Was the patients ER status assessed
at time of diagnosis or recurrence?
Was the patients HER2 status
assessed at time of diagnosis or recurrence
Were results for both HER2 and ER
status available within 2 weeks
Results – Pathology ER/HER2 status
ER st
atus asse
ssed
HER2 status a
ssesse
d
Both resu
lts av
ailable w
ithin 2 w
eeks0%
40%
80%
120%Assessment of ER/HER2 status
Leeds MY Brad
%
ER status HER2 status0%
20%
40%
60%
80%
100%
120%
Availability of results within 2 weeks
Leeds MY Brad
%
Results Done well across the region Only delays were in HER2 testing, most awaiting dDISH Lower percentage of HER2 results available within 2 weeks from BRI – is there anything that can be learnt from this or is it just a statistical quirk/feature of the sample period? Predictably more reliable in tertiary centre – testing done on-siteRecommendations? any value in taking a closer look at HER2 results in BRI (may be that this is not an issue!)
Results - Management“People with early invasive breast cancer, irrespective of age, are offered surgery, radiotherapy and appropriate systemic therapy, unless significant comorbidity precludes it.”
If TNBC, did the patient receive
adjuvant chemo (or NACT)
Did the patient receive
radiotherapy post BCS
Grouped into patients older and younger than 70
Results
Chemo in TNBC <70 70+0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Chemo in TNBC - Cross site
Leeds MY Brad0%
20%
40%
60%
80%
100%
Chemo in TNBC
Leeds MY Brad0%
20%40%60%80%
100%
Age distribution - chemo in TNBC
<70 70+
Results - Chemotherapy 22 TNBC patients identified across the 3 sites
Only 3 patients did not receive chemotherapy – either due to patient choice or condition. All 3 patients were in the >70 age group
All TNBC patients <70 received adjuvant/neoadjuvant chemotherapy.
Appropriate use of therapeutic options in TNBC, meeting high standards across the network
Confusion on the audit tool – adjuvant and NACT – need to clarify!
Recommendations
Continue current management
Results - Radiotherapy
RT post BCS <70 70+0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
RT post BCS - cross site
Leeds MY Brad0%
20%40%60%80%
100%RT post BCS
Leeds MY Brad0%
10%20%30%40%50%60%70%80%90%
100%
Age distribution - RT post BCS
<70 70+
Results - Radiotherapy Of the BCS patients, only 6 did not have post-op radiotherapy in this sample
Mostly documented as being due to patient choice or condition
Group of patients not undergoing radiotherapy predictably made up of a higher proportion of >70s
Meets high standards across the region
Recommendation
Continue current management
Results - Patient information“People having treatment for early breast cancer are offered personalised information and support, including a written follow-up care plan and details of how to contact a named healthcare professional”
Did the patient receive a written
information pack regarding the different treatments available to them and
possible side effects?
Did the patient receive written information re dates of follow
up, adjuvant therapy review
and surveillance?
Did the patient receive contact
details of a named
healthcare professional?
Did the patient receive
information about the available
psychological and emotional
support?
Results – Patient information
Leeds MY Brad0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Patient information
Treatments/side effects Follow upContact details Emotional/psychological support
Results – patient information Provided the most variable results across the audit standards Difficult data to access retrospectively Bradford do especially well - entry added directly into PPM when primary information pack is given, with documented evidence of multiple documents for treatment info/support. May be variation within people collecting data – do junior doctors have different standards to specialist nurses who, for example, do the information giving on a daily basis?
Recommendations Use of a standardised method of information giving/recording Could review pack where already in use to check it contains follow up details etc (or make sure this is recorded elsewhere) May need to evaluate what aspects of this standard are actually important (do patients necessarily read/need more information to improve their experience?
The process What went well –
Large amount of data collected in a relatively short amount of time Provides a “snapshot” of service provision across the region Enables discussion between units as to how to improve services where results are variable Could become a method of repeatedly auditing services on a larger regional/national scale.
What could be improved – Difficulty when multiple people collect data – data quality, clarity of exceptions etc Need to clarify some of the standards for ease of data collection Audit tool maybe too rigid – more space to input data freely in order to improve data quality and analysis. Some technological blips in audit spreadsheet – to be smartened up a bit if used again!
Where next? Identified key areas for further audit With some deeper thought into the ergonomics/content could be a good yearly benchmark across the region ? Participation across more centres ? Input from others as to what to include/way of improving data quality/participation
Thanks to Luke Wreglesworth (LTHT), Mandy Blackburn (BRI), Julie Davies, Leanne Howard, Debbie Hepworth, Michele Smith, Helmy Mashaly, Deviner Gupta and Parisha Bisram (MY) for collecting the audit data.
Thankyou! Any questions?