The first annual report by a national audit of breast surgery services suggests some trusts are failing to follow NICE guidance in key areas. Nerys Hairon reports
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The first annual report from the National Mastectomy and Breast Reconstruction Audit in England and Wales has revealed widespread differences in access to immediate reconstruction surgery for patients with breast cancer (NHS Information Centre et al, 2008). The report also shows shortages of breast care nurses.
This indicates there has been a failure to implement key aspects of NICE (2002) guidance, which recommended that immediate reconstruction should be made available to all women having a mastectomy.
The first of its kind in the world, the audit project has been commissioned and funded by the Healthcare Commission to assess and improve quality of care for women with breast cancer who are having mastectomy and breast reconstruction surgery.
Breast cancer is the most common form of female cancer, accounting for nearly 30% of all cases of cancer in women. There were 39,301 new cases of breast cancer among women in England and Wales in 2004, an increase of 27% over 10 years.
The audit project began in January 2007 and is designed as a four-year initiative. Its main focus is to study a cohort of women having mastectomy or reconstruction surgery during 2008.
To provide a full picture of breast cancer services in England and Wales, the project carried out three additional pieces of work in 2007. These comprised: a qualitative study of interviews with 30 people (including patients, nurses, medical staff and service providers); a survey of 144 NHS trusts and 143 independent hospitals in England and Wales; and an analysis of hospital episode statistics in England. The results of this additional work form the basis of the first annual report.
The qualitative study revealed a general perception that a good surgical service is available for women with breast cancer in England and Wales.
However, the report also identifies considerable pressures on services, such as a need to provide more operations because of the rising incidence of breast cancer and the need to provide a higher proportion of women with reconstruction after mastectomy. Pressures from cancer waiting-time targets are another factor.
To meet this increased demand for services, the number of operations performed in the NHS in England increased by 37%, from 24,684 to 33,814, between 1997 and 2006.
Complying with NICE guidance
NICE (2002) recommended that immediate reconstruction should be available to all women undergoing mastectomy. The number of immediate reconstruction operations provided by the NHS in England almost doubled between 1997 and 2006.
However, the proportion of all women having mastectomy who had an immediate reconstruction increased only slightly, from 7% to 11%. The audit report states this indicates there have been difficulties in implementing NICE guidance.
In addition, the audit found that local access to breast reconstruction services varies across England and Wales. More than one-quarter (26%) of English NHS trusts that performed mastectomy surgery in 2005–2006 did not provide immediate reconstruction. However, this figures is lower than previously.
NICE guidance (2002) advised that surgeons should discuss breast reconstruction with all patients and that reconstruction should be available at the initial surgical operation. It adds that, if this cannot be provided within one month of diagnosis, women should be offered a choice between routine surgery with delayed reconstruction (if desired) or waiting longer for initial surgery. When women choose the second option, the reason for the delay should be recorded.
When directly asked, 92% of NHS trusts and 82% of independent hospitals reported that they comply with NICE guidance on access to immediate reconstruction surgery. The audit report points out, however, that it is not clear whether this refers to offering the option of immediate reconstruction or to facilitating delayed reconstruction instead.
In 2005–2006, 36 NHS trusts performed delayed breast reconstruction surgery but no immediate reconstructions. Since both immediate and delayed surgery require specialist surgical skills and ward support for post-operative care, the report says there is no obvious clinical reason not to provide immediate reconstruction at a centre where delayed procedures are available.
The audit also found considerable variation in both the NHS and the independent sector in the use of chemotherapy before surgery to enable immediate reconstruction to be offered.
Chemotherapy before surgery is increasingly being used to achieve loco-regional control in women with high-grade tumours, and locally advanced or metastatic cancer. After recovering from chemotherapy, mastectomy and immediate reconstruction may then be carried out.
Three-quarters of NHS trusts said they would provide such chemotherapy to patients with high-grade or locally advanced disease to enable immediate reconstruction. However, only 55% would offer it to patients with metastatic disease, while 45% would not.
Nearly three-quarters (72%) of independent hospitals said they would provide this option to women with metastatic disease. These centres appeared more willing to provide this kind of treatment to all three groups.
The report concludes that this variation is likely to create inequities in access to immediate breast reconstruction.
Breast care nurses are vital in supporting patients while making a decision about whether to have a breast reconstruction at the same time as their mastectomy. NICE (2002) guidance recommended that a specialist breast care nurse should be available to all patients with breast cancer, and involved as a core member of any breast cancer multidisciplinary team. Most NHS trusts (97%) and independent hospitals (89%) said they have a dedicated breast care nurse. The report says it is surprising that 11% of independent hospitals providing breast cancer surgery do not meet the standard set out in NICE guidance.
For those that do have them, NHS trusts employ an average of three breast care nurses and independent hospitals an average of 1.5 nurses. However, 5% of NHS trusts and 43% of independent hospitals reported that they employ only one breast care nurse.
The report highlights the problems associated with employing only a single breast care nurse. It points out that patients may be unable to access specialist nursing care if this nurse is absent on annual or sick leave.
The qualitative study revealed that communication with patients was one of seven key aspects of high-quality care for those having breast surgery (see box, below). Participants felt that providing patients with appropriate and sufficiently detailed information about breast cancer surgery is essential. Patients in the study highlighted a number of problems, including poor quality of information given, insufficient information early in the treatment process, and breast reconstruction being offered in a discouraging way.
The report says there is a perception that the funding climate in the NHS prevents increased access to breast reconstruction.
It suggests that some commissioners may create barriers to availability by, for example, insisting on a psychological evaluation.
Time to allow informed and reasoned decision-making featured strongly as an issue in the qualitative study. The decision on whether to proceed with immediate breast reconstruction is difficult and women need time to digest the information and consider the choices available. While timely care is important, patients need time to ask questions and to avoid making complex decisions without sufficient information.
There is a perception that decisions about reconstruction often become a secondary concern because of the urgent need to ensure patients have definitive treatment within the 62-day target outlined by The NHS Cancer Plan (Department of Health, 2000).
The report says the most important issue identified is inequity of access for women who want an immediate breast reconstruction. Despite NICE guidance recommending this as an option, there has been limited progress to date on this issue. A number of barriers must be overcome before full implementation is possible.
Key aspects of high-quality care
Department of Health (2000) The NHS Cancer Plan: a Plan for Investment, a Plan for Reform. www.dh.gov.uk
NICE (2002) Guidance on Cancer Services: Improving Outcomes in Breast Cancer – Manual Update. London: NICE. www.nice.org.uk
The NHS Information Centre et al (2008) First Annual Report of the National Mastectomy and Breast Reconstruction Audit 2008. Leeds: TNIC. www.ic.nhs.uk