NHSBSP Surgical QA Data for the Year of Screening 1 April 2002 to 31 March 2003

1. NHSBSP Surgical QA Data for the Year of Screening 1 April 2002 to 31 March 2003 Dr Gill Lawrence and Professor Jan Frisell on behalf of ABS at BASO

2. Acknowledgements • Mr Hugh Bishop • Mr James Bristol • Mr Mark Kissin • Dr Gill Lawrence • Mrs Julietta Patnick • Ms Jacquie Reed • Ms Nicola Richmond • Prof Paul Sauven • Dr Matthew Wallis • Dr Jackie Walton • Mrs Margot Wheaton The BASO Breast Audit Group would like to extend their thanks to all NHS and ABS at BASO staff who contributed to the 2002/03 ABS at BASO Breast Audit

3. Acknowledgements • ABS at BASO • Surgical QA Co-ordinators • Ms Lucy Davies • Breast Screening QA Reference Centres • QA Directors • QA Co-ordinators • QA Data Managers • Screening Services • Screening Office Managers • Surgeons • Regional Cancer Registries • West Midlands Cancer Intelligence Unit

4. Setting the scene Number of cancers and consultant surgeons in the UK NHSBSP

5. * * * * * * *boundary changes Regions supplying data * name changes

6. UK - all cancers 6.9 per 1000 UK - non inv/micro 1.5 per 1000 Cancer detection rates 2000-03

7. Screening surgical caseload • Surgical specialisation most advanced in West Midlands and Northern Ireland • In North West, 60 women were under the care of more than one consultant surgeon • London and East of England were unable to provide a reason for low caseload for more than 20 surgeons

8. Pre-operative diagnosis X

9. UK 91% Pre-operative diagnosis rate Min std 80%

10. Target 90% Pre-operative diagnosis rate Min std 80%

11. Pre-operative diagnosis rate (7 year comparison)

12. 86% 91% 81% 89% North West 86% 92% 89% 88% N Ireland 3 year comparison Scotland Non inv Wales

13. 38% 33% Invasive status after B5a (Non-invasive) core biopsy UK 24%

14. Invasive status after B5a (Non-invasive) core biopsy UK 24%

15. Repeat visits to achieve a pre-operative diagnosis UK 2+ visits 12%

16. Diagnostic open biopsies

17. Open biopsy rates 4749 2734M + 2015B 2919 1018M + 1901B

18. Open biopsy rates per 1000 women screened North West Wales Highest rates in UK in 2000/01

19. Type of surgical treatment provided to non-invasive and invasive breast cancers

20. Treatment for non & micro-invasive cancers 2002/03 UK 69%

21. Treatment for non & micro-invasive cancers 2000-03 UK 69%

22. Non-invasive cancers treated by conservation surgery Sloane Project data items grade size margin status *counts each cancer once only

23. 4x NEYH Treatment for all invasive cancers 2000-03 Yellow line through the Midlands (East and West) Blue above this line (Scotland, N Ireland, NEYH, North West, Wales) Red below this line (E of England, London, South East (E & W), South West) UK 28%

24. Yellow line through the Midlands (East and West) Blue above this line (Scotland, N Ireland, NEYH, North West, Wales) Red below this line (E of England, London, South East (E & W), South West) 3x NEYH Treatment for invasive cancers <15mm 2000-03 UK 20%

25. Mastectomy rates according to tumour size • Mastectomy rates are lower if whole size is taken into consideration • Presence of DCIS increases mastectomy rate

26. UK 15% whole size * * * * Mastectomy rates according to tumour size 14% immediate reconstruction UK 19% invasive size Reconstruction audit

27. Lymph nodes and invasive grade

28. 10 units complete nodal information Invasive cancers with nodal status unknown 1 unit complete nodal info for 2000-03 7/8 London units >2x UK average UK 5.3%

29. Insufficient nodal information for invasive cancers * * excludes sentinel nodes

30. Insufficient nodal information for invasive cancers UK 8.8%

31. Non-invasive cancers with known nodal status 41% mastectomies UK 29% UK 26%

32. Nodal status and pre-operative history Why take nodes for B5a? conservatively treated non-invasive cancers

33. Invasive grade 1 unit no data

34. NPI

35. Repeat therapeutic operations 90% of cancers with single lesions (excluding multi-focal tumours and those with extensive DCIS) should not require a further operation to ensure complete excision

36. UK 16% non-invasive Repeat operation rates UK 14% invasive

37. Margins not clear - repeat operation conservation or mastectomy 2 Expected tumour component 3 Small B5b (invasive) with unexpected DCIS Insufficient no. obtained at 1st operation Additional nodal procedure 4 Therapeutic clearance after large no. +ve Clearance after +ve sentinel node Repeat operations - possible scenarios Invasion not predicted by pre-operative diagnosis - repeat operation to obtain nodes B5a (non invasive) invasive after surgery 1 C5 nodes not taken at first operation

38. 84% 1 operation inc Ax 12% repeat operation 5% no Ax B5b invasive after surgery

39. Nodal status for B5b invasive after surgery 31% no Ax surgery UK 94% first operation 1% repeat operation

40. 80% 1 operation inc Ax 13% repeat operation 5% no Ax C5 only invasive cancers

41. Nodal status C5 only invasive after surgery 16% no Ax surgery UK 91% first operation 3% repeat operation 23% no Ax surgery

42. 46% 1 operation inc Ax 41% repeat operation 34% Ax at repeat operation 14% no Ax B5a invasive cancers

43. 24% no Ax surgery 31% no Ax surgery Nodal status B5a invasive after surgery 60% at repeat op 70% at first op UK 51% first operation 34% repeat operation

44. Which pathways were followed? How long did it take to get there? ? What combinations of treatments were given? Adjuvant therapies

45. UK 72% RT, CT, HT complete 76% RT, CT complete Data completeness for RT, CT, HT start dates 84% some data supplied (77% last year)

46. UK 63% non-invasive Unknown ER status UK 9% invasive

47. UK 50% known for ER –ve cancers Data completeness for PgR status UK 30% known all cancers

48. Data completeness for Cerb-B2/HER-2 status UK 11%

49. Times to first treatment and from first treatment to adjuvant therapy

50. Median days between therapies Shading:orange10% above UK, green 10% below UK