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Progress in establishing best practice clinical guidelines for breast cancer in New Zealand. Libby Burgess 10 th June 2006. Overview. Best Practice Clinical Guidelines What are they? Why do we need them? Australian Guidelines and Clinical Updates NZ Guidelines

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Progress in establishing best practice clinical guidelines for breast cancer in New Zealand

Libby Burgess

10th June 2006

  • Best Practice Clinical Guidelines
    • What are they?
    • Why do we need them?
    • Australian Guidelines and Clinical Updates
    • NZ Guidelines
    • Fit with Cancer Control Strategy
    • BCAC advocacy on Guidelines
    • Benefits of consumer (patient/survivor) involvement
evidence based clinical practice guidelines
Evidence-based clinical practice guidelines
  • Valuable resources guiding the work of health professionals
  • Promote awareness of the most effective strategies based on the latest
  • evidence
  • Improve the processes of care for patients, reducing errors and variation,
  • providing a consistent high quality of care
  • Improve patient outcomes
  • Provide cornerstones of accountability and facilitate learning by medical
  • practitioners
    • Regular updating needed to incorporate new knowledge
    • Monitoring needed to ensure uptake by practitioners
why we need breast cancer guidelines in nz
Why we need breast cancer guidelines in NZ
  • To achieve:
  • Early detection, accurate diagnosis, appropriate,
  • timely treatment
  • Consistency of high quality care throughout NZ
  • Best possible outcomes for patients
why we need breast cancer guidelines in nz5
Why we need breast cancer guidelines in NZ
  • Currently many inconsistencies exist around New Zealand, e.g.:
    • GP and specialist views on screening
    • Access to screening
    • GP response to symptoms
    • Availability of multi-disciplinary medical team
    • Surgical treatment (e.g. mastectomy vs breast conservation)
    • Radiotherapy (e.g. local boost or not)
    • Waiting times to see a specialist, receive surgery, chemo & radiotherapy
    • Drug access
    • Histology and tests performed
    • Availability of reconstruction
  • Differences in access regionally and racially
  • Māori women:
  • 21% more likely to be diagnosed with breast cancer
  • 30% less likely to be diagnosed early
  • 68% more likely to die from it
  • Robson, Purdie & Cormack, 2006. Unequal Impact: Māori and non-Māori Cancer Statistics 1996 – 2001
australian breast cancer guidelines
Australian Breast Cancer Guidelines
  • The investigation of a new breast symptom- a guide for general practitioners (2006)
  • Advice about familial aspects of breast cancer and epithelial ovarian cancer – a guide for health professionals (2006)
  • Breast fine needle aspiration cytology and core biopsy; a guide for practice (2005)
  • Clinical practice guidelines for the psychosocial care of adults with cancer (2005)
  • Multidisciplinary meetings for cancer care - a guide for Health Service Providers (2005)
  • The clinical management of DCIS, LCIS, & atypical hyperplasia of the breast (2003)

Produced by Australia’s National Breast Cancer

australian breast cancer guidelines7
Australian Breast Cancer Guidelines
  • Clinical practice guidelines for the management and support of younger women with breast cancer (2003)
  • The management of the woman with metastatic breast cancer (2003)
  • Breast imaging: a guide for practice (2002)
  • Clinical practice guidelines for the management of early breast cancer (2001)
  • Clinical practice guidelines for the management of advanced breast cancer (2001)
  • The pathology reporting of breast cancer, a guide for pathologists, surgeons, radiologists and oncologists (2001)
  • Radiotherapy and breast cancer (1999)

Produced by Australia’s National Breast Cancer

australian clinical updates
Australian Clinical Updates
  • Inform clinicians of the latest advances in knowledge, rapidly incorporated into practice
  • Fatigue in long-term breast carcinoma survivors (2006)
  • Diagnostic performance of digital versus film mammography for breast
  • cancer screening (2005)
  • Efficacy of prophylactic mastectomy in women with unilateral breast
  • cancer (2005)
  • Adjuvant chemotherapy in older and younger women with lymph node-
  • positive breast cancer (2005)
  • Radiation Therapy and Chemotherapy vs Chemotherapy alone: 20-year
  • results of the British Columbia randomized trial (2005)
  • Anastrozole vs Tamoxifen: Impact on Quality of Life (ATAC 2 Year Assessment)
  • (2004)
  • Radiotherapy with tamoxifen after lumpectomy for early breast cancer –
  • does it make a difference for women in different age groups? (2004)
  • Letrozole after tamoxifen in early breast cancer. (2004)
  • Produced by Australia’s National Breast Cancer
australian clinical updates9
Australian Clinical Updates
  • Delay in starting radiotherapy: does it make any difference? (2004)
  • History revisited: Did NSABP TRIAL B04 get it right? (2004) Written by a NZ doctor!
  • Adjuvant radiation and/or tamoxifen after surgery for DCIS (2004)
  • Dose-dense chemotherapy as adjuvant treatment in early breast cancer (2004)
  • Chemoprevention: is the jury still out? (2004)
  • Fractionation in radiation therapy – perhaps one size doesn’t fit all (2003)
  • Tailoring adjuvant treatment for post-menopausal node-negative breast cancer (2003)
  • Aromatase inhibitors – ready for centre stage? (2003)
  • Hormone replacement therapy – is it a treatment of the past? (2003)
  • Managing menopausal symptoms in women following breast cancer treatment (2002)
  • Managing hot flushes in women treated for breast cancer (2002)
  • Produced by Australia’s National Breast Cancer
nz guidelines are woefully inadequate
NZ Guidelines are woefully inadequate
  • NZ Guidelines
    • Guidelines for the early detection of breast cancer (1999)
      • Don’t reflect government policy of screening 45-69yr band
      • RNZCGP sought MoH funding for an update, unsuccessful
    • Guidelines for the surgical management of breast cancer (1997)
      • Written prior to sentinel node biopsy and other advances
  • Comparative survival data
    • NZ 28% worse than Australia (Skegg & McCredie, 2002)
guidelines fit with cancer control strategy
Guidelines: fit with Cancer Control Strategy
  • Purposes:
    • Reduce incidence & impact of cancer
    • Reduce inequalities wrt cancer
  • Principles:
    • Activities of high quality:
      • need standards & guidelines, monitoring & evaluation
  • Goals:
    • Ensure effective screening and early detection to reduce cancer incidence and mortality:
      • need guidelines for referral and ongoing assessment
    • Ensure effective diagnosis and treatment to reduce cancer morbidity and mortality:
      • need defined standards for diagnosis, treatment and care; consistently applied guidelines & monitoring of their use
  • Important area of action:
  • “the development, implementation and ongoing refinement of national and regional standards, guidelines and protocols”.
guidelines fit with cancer control action plan
Guidelines; fit with Cancer Control Action Plan
  • Goal 3: Ensure effective diagnosis and treatment of cancer to reduce morbidity and mortality
  • Obj 1: Provide optimal treatment for those with cancer
  • Obj 2: Develop defined standards for diagnosis treatment and care for those with cancer
    • Establish timeframes for timely diagnosis & treatment; monitor and record; reduce access delays; develop referral guidelines
    • Develop guidelines for diagnosis, treatment and management of cancers
    • Develop protocols and guidelines regionally and nationally
guidelines bcac action
Guidelines: BCAC action
  • Researched the topic to identify existing NZ guidelines; compared these to Australian resources
  • Advocated the urgent need for development & updating of BC guidelines to NZ Guidelines Group (Aug 05)
    • To be based on existing Aussie and other guidelines
  • Sought support for this initiative by writing to 15 medical bodies, 9 MPs and other interested parties (Aug 05)
  • Received supportive responses (Sept 05)
    • From wide range of medical bodies
    • From NZGG though they claimed they would need a sponsor before acting
    • MPs were busy getting elected
  • Met with and lobbied Dr John Childs, Principal Advisor, Cancer Control (Sept 05)
    • For: Breast Cancer Guideline development; Consumer input; Regular updating; Monitoring to ensure implementation
guidelines bcac action14
Guidelines: BCAC action
  • Received a positive response from John Childs:
    • “Breast cancer guidelines will be developed first and will provide a model for other cancers” (Sept 05)
  • Briefed key decision-makers in Wellington (on all 4 BCAC issues) (Dec 05)
    • Minister of Health, selected MPs, health officials & medical practitioners
  • Regular contact withJohn Childs, requesting & receiving updates, providing new info e.g. new Scottish guidelines… but progress slow. By June 06:
    • NZGG has developed a proposal for cancer guideline development including breast
    • will adapt recent international guidelines
    • will consult stakeholders
    • contract to be signed July 2006
    • guideline to be completed Sept. 2007
guidelines bcac ongoing action
Guidelines: BCAC ongoing action
  • Advocating to have consumer involvement in guideline development (and at governance level of Cancer Control Council)
    • Invited to send a breast cancer patient advocate delegate to northern region DHB consultation group
    • No access to higher levels yet
  • Building Māori capability (Carlene & friends) to enable networking so we can consult & include Māori women, identify advocacy targets, help close the gaps
  • Need to devise effective strategies for beating bureaucratic resistance to:
    • timely progress
    • consumer/patient/advocate involevment
the value of consumer participation in cancer control incl guideline development
The value of consumer participation in Cancer Control incl. guideline development
  • Experience of cancer
    • We know how it feels to be diagnosed with this deadly disease
  • First-hand knowledge of existing services - what is good, what needs improvement and what is missing
    • It’s personal, not just hypothetical
  • Our networks inform us of the experiences of others with cancer
    • We’re well-informed
  • Motivation and passion to drive improvements
    • We genuinely want to contribute, and care about the outcome
the value of consumers in participating in establishment of nz cancer guidelines
The value of consumers in participating in establishment of NZ cancer guidelines
  • Independence of professional/government bodies & their constraining elements, e.g.:
    • Budgetary constraints
    • Influential leaders and their views
    • Interdisciplinary/departmental/organisational competition for resources/status
    • Patch protection
    • We will keep our eye on the ball. We can see the bigger picture We are patient-focused
  • Participation in the community that will be served by improvements
    • These are our people. Our advocacy is trusted. Changes we have helped to bring about are more likely to be adopted