Audit shows breast cancer patients have increased access to immediate reconstructive surgery, but highlights the need for more improvement

The proportion of women offered or undergoing immediate reconstruction also varies significantly by region according to the audit, published today by the NHS Information Centre and the Royal College of Surgeons of England on behalf of the Healthcare Quality Improvement Partnership.

The National Institute for Health and Clinical Excellence (NICE) recommends immediate breast reconstruction should be discussed with all patients who are advised to have a mastectomy and should be offered to all, except where a patient's health or treatment plan would make them unsuitable for the procedure.

The audit also raises questions about how the offer of immediate reconstruction is communicated to patients, after it found the proportion of women who accepted an offer varied regionally from 17 per cent in one cancer network to 62 per cent in another.

All 150 English NHS trusts that provide breast cancer surgery, six non-English NHS trusts, and 106 independent hospitals participated in the audit which was able to examine about 74 per cent of all cases involving adult women who had mastectomy or reconstructive breast surgery between January 1 2008 and March 31 2009. The audit found:

  • 21 per cent of women who had a mastectomy (15,479) had immediate reconstruction; just under half of women who had a mastectomy (48 per cent) were offered the procedure.
  • The rate of immediate reconstruction across England's 30 cancer networks varied from nine per cent to 43 per cent, with most networks reporting a rate of between 14 and 27 per cent. The rate of offer of immediate reconstruction also varied. However, there is no strong correlation between the two rates.
  • In most cases, the reason clinicians gave for not offering immediate reconstruction was that the patients were deemed inappropriate for surgery due to clinical, health or lifestyle problems, or where there was a perceived need for adjuvant therapy, such as chemotherapy or radiotherapy. However in five of the 30 networks the reason stated was “the lack of a local or timely reconstructive service” for more than 30 per cent of patients.

The audit notes the increased demand for breast cancer surgery during the last decade due to the corresponding increase in the incidence of the disease. The number of breast cancer operations increased from 24, 684 in 1997 to 33,814 in 2006, a 37 per cent increase.

Its recommendations include:

  • NHS trusts and independent hospitals should review the way in which they offer reconstruction, to ensure barriers to women accepting the offer are minimised.
  • Cancer networks should also improve local access by ensuring adequate service provision to meet the increasing demand.
  • Cancer networks should ensure women are able to access all appropriate reconstructive options within current waiting times, even if not locally.

NHS Information Centre Chief Executive Tim Straughan said: “This is the second of four reports from the National Mastectomy and Breast Reconstruction Audit, which is the first of its kind in the world and provides the NHS with the comprehensive information it needs to better plan and improve breast cancer surgery services.

“The fact that all NHS trusts in England that provide breast cancer surgery took part in the audit shows an excellent commitment from all those involved with the care of breast cancer patients and a desire to contribute to this very important study. The audit clearly shows an improvement in the proportion of women having immediate reconstruction but highlights the need to improve access and the way the procedure is offered to patients.”

Robin Burgess, Chief Executive of the Healthcare Quality Improvement Partnership, said “It is important that women with breast cancer who have a mastectomy are offered the choice of breast reconstruction immediately. This can not only help reduce the number of operations needed but also minimise the psychological impact of a mastectomy.

"This is a failure to offer patients the choice they are entitled to, one for which they should have access to better information. Patients have a right to be treated as equals in their choice of treatment, in-line with clinical recommendations and best practice.

“This audit, as with several audits in our national programme, highlights the shortfalls occurring and makes recommendations which can directly lead to improvements in the level of care received by patients.”

Consultant General and Oncoplastic Breast Surgeon and clinical lead for the audit, Jerome Pereira, said: “This audit has the potential to improve quality and outcomes following breast cancer surgery, worldwide.

The enthusiasm and commitment of surgeons to provide high quality care for our patients is demonstrated by the fact that all 150 English NHS Trusts and 106 independent hospitals are committed to the programme. Though it is encouraging to note a doubling in reconstruction surgery rates, there are key lessons to be learnt from this second annual report. Cancer networks have a responsibility in implementing the key recommendations in order to improve communication and access and increase resources to provide breast reconstruction within the 31 day target.”

Breast cancer nurse and audit project team member, Carmel Sheppard, said: “This audit provides significant information to breast care nurses, who play a pivotal role in supporting women throughout the patient journey. Breast care nurses have a central role in providing information to patients to facilitate choice and decision making regarding treatment.

“It is fantastic news that access to reconstruction has increased and this audit provides us with new opportunities to now explore potential difficulties that some units have. As nurses we must continue to advocate for greater patient access ensuring that all women suitable for reconstructive surgery are provided with equal opportunities to access their treatment of choice.

Consultant Reconstructive Plastic Surgeon Chris Caddy, audit representative for the British Association of Plastic, Reconstructive and Aesthetic surgeons said: “This audit is very much a 'world first', which will allow improved counselling of patients with regards to complication and outcomes. We are very proud of what we have achieved to date. However, there are challenges that have been highlighted and these need to be looked at carefully. There is huge variation in access to reconstruction, both in the way that the opportunities are communicated and surgical expertise is made available.

"The report confirms the fundamental need for all medical professionals involved in breast cancer care to work collaboratively to improve levels of care and outcomes for patients. As a plastic surgeon I am keen that we have a physical presence on every breast Multi Disciplinary Team (MDT) throughout the UK, to help deliver the best treatment and outcomes for patients."

The audit can be accessed at www.ic.nhs.uk/mbr from 00.01 on October 05 2009.

Notes to editors

  1. The NHS Information Centre for health and social care (The NHS IC) is England's authoritative, central, independent source of health and social care information. It works with a wide range of health and social care providers nationwide to provide the facts and figures that help the NHS and social services run effectively. Its role is to collect data, analyse it and convert it into useful information which helps providers improve their services and supports academics, researcher, regulators and policymakers in their work. The NHS IC also produces a wide range of statistical publications each year across a number of areas including: primary care, health and lifestyles, screening, hospital care, population and geography, social care and workforce and pay statistics.
  2. The Healthcare Quality Improvement Partnership (HQIP) is led by a consortium of the Academy of Medical Royal Colleges, the Royal College of Nursing and National Voices. Its aim is to promote quality improvement, and in particular to increase the impact that clinical audit has on healthcare quality in England and Wales. HQIP hosts the contract to manage and develop the National Clinical Audit and Patient Outcomes Programme (NCAPOP). Their purpose is to engage clinicians across England and Wales in systematic evaluation of their clinical practice against standards and to support and encourage improvement in the quality of treatment and care. The programme comprises more than 20 clinical audits that cover care provided to people with a wide range of medical, surgical and mental health conditions, including mastectomy and breast reconstruction.
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