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National Public Health Service for Wales
Rapid Review of Breast Care Services in North Wales
Rapid Review of Breast Care Services in North Wales
Authors: Dr Rob Atenstaedt (Health & Social Care Quality Team & Local Public
Health Director, Conwy & Denbighshire LHBs and) - lead; Dr Julia Williams
(Associate Local Public Health Director, Conwy & Denbighshire LHBs) - support; Mr
Andrew Jones, Regional Director of Public Health.
Date: 5/12/08
Version:5
Status: Approved
Intended Audience: Public (Internet); NHS Wales (Intranet); NPHS (Intranet);
Health & Social Care Quality Team (Intranet)
Purpose and Summary of Document:
This document brings together information on a rapid review of breast care services
in North Wales performed by the National Public Health Service for Wales on behalf
of the North Wales Cancer Network.
Publication/Distribution:

Publication in NPHS Document Database (Health & Social Care Quality)

Link from NPHS e-Bulletin

Link from Stakeholder e-Newsletter
Author: Dr Rob Atenstaedt,
Dr Julia Williams, Mr Andrew Jones
Version: 5
Date: 5/12/08
Status: Final
Page 1 of 132
Intended Audience: Public (Internet)
/ NHS Wales (Intranet)
National Public Health Service for Wales
Rapid Review of Breast Care Services in North Wales
Executive Summary
1.1 Background
Breast disease is a major public health problem in Wales as it is a significant cause
of morbidity and mortality. In addition, breast care services consume substantial
resources for NHS Wales.
A review of breast surgery services at Llandudno Hospital (limited to services
provided in Mid and West areas of North Wales) by Holcombe and Raynor and a
review of the future role of Llandudno Hospital by Burns were both undertaken in
2007.
The Welsh Health Minister has recently stated that ‘the current breast care service
should remain at Llandudno for the foreseeable future whilst further work and advice
is provided on a model of breast care services in North Wales’.
The North Wales Cancer Network was requested by Conwy Local Health Board
(LHB) to lead on a project to develop an agreed model for breast care services for all
of North Wales.
To support the project, the National Public Health Service for Wales (NPHS) was
asked to provide specialist public health support to the Cancer Network. Due to the
short timescale available a rapid review only has been undertaken, using NPHS
methodology for conducting service reviews/ design. The review builds on previous
work undertaken by Holcombe and Raynor.
This draft report describes key information required to facilitate the identification and
consideration of options for the configuration of high quality breast care services for
the North Wales population.
1.2 Scope
All female breast disease has been considered, together with all aspects of breast
services including prevention, screening, diagnosis, treatment and follow-up and
related services including breast plastic surgery, breast radiology and pathology.
Whilst the symptomatic services in the review are all part of the North Wales health
community, recognition is given to the fact that breast screening services are
provided by Breast Test Wales which is an all Wales service working to all Wales
protocols.
1.3 Healthcare Needs Assessment
Author: Dr Rob Atenstaedt,
Dr Julia Williams, Mr Andrew Jones
Version: 5
Date: 5/12/08
Status: Final
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Rapid Review of Breast Care Services in North Wales
Breast cancer is the most common cancer in women in the UK. There are 2500
cases of female breast cancer in Wales every year. There has been a steady rise in
the incidence of breast cancer in the UK, though mortality from the disease has
fallen since 1989. Survival from breast cancer in the UK has improved significantly
over the last three decades.
Risk factors for breast cancer include old age, early menarche, late first pregnancy,
low parity, and late menopause, which are not amenable to primary prevention.
Alcohol consumption is associated with an increased risk of breast cancer, and
avoidance of obesity after menopause may decrease the risk of breast cancer..
Women who breast feed are less likely to develop breast cancer. About 5% of breast
cancer has a genetic origin.
The population of North Wales, currently 670,000, is predicted to increase to almost
700,000 by 2028. The next 20-30 years are likely to see a large growth in the
number of older people in North Wales which will have an impact on breast cancer
rates in the population, as one of the main risk factors for the disease is old age. The
incidence of breast cancer has increased in all LHB areas in North Wales over the
last 10 years, although the gap between the counties has narrowed in this period.
Predictions by the Welsh Cancer Intelligence & Surveillance Unit are that breast
cancer in the region is likely to increase by between 15% and 36% by 2016-20.
In general, mortality from breast cancer is higher and survival is lower in more
deprived communities. Tackling health inequalities remains a key issue in North
Wales, with almost one fifth of the population living within the most deprived wards in
Wales being located within North Wales local authority boundaries (notably in
Gwynedd and Wrexham). Deprivation is also accentuated by the rural nature of
much of North Wales and the relatively poorly developed road system, which can
make geographical access to health services an issue.
Breast Test Wales screens approximately 20,000 women each year in North Wales
and detect on average 200 cancers. It is therefore important that screening services
for the whole population are appropriately considered in any redesign of breast care
services, as healthy women comprise the vast majority of women presenting to
services. Round 5 breast screening uptake in North Wales was lower than the Welsh
average. Within North Wales, the screening uptake rate was lowest in Denbighshire,
and highest in Anglesey.
It is estimated that there are at least 25,000 women under the age of 65 in North
Wales who will develop benign breast disease in their lifetime. The highest
proportions of these are currently resident in Flintshire and the lowest in Anglesey. It
is therefore important that women with benign breast disease are considered in any
redesign of the breast care service for North Wales residents as they comprise the
vast majority of women with breast disease.
Wales has the second highest rate of breast cancer in the UK, as well as the second
highest mortality rate. There are, on average, 565 cases of breast cancer per year in
North Wales and the overall standardised incidence rate in North Wales is higher
than the Welsh average. There are, on average, 179 deaths from breast cancer in
Author: Dr Rob Atenstaedt,
Dr Julia Williams, Mr Andrew Jones
Version: 5
Date: 5/12/08
Status: Final
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Rapid Review of Breast Care Services in North Wales
North Wales every year and again this is higher than the Welsh average. Both these
statistics signify that North Wales has a greater need for breast cancer services than
Wales in general. Survival from cancer is, in general, better in North Wales. Five
year relative survival from breast cancer in North Wales is lowest in Anglesey,
Gwynedd, and Denbighshire, and highest in Flintshire.
Overall, the greatest overall burden of breast cancer in North Wales (and so the
greatest relative need for service provision) is in the counties of Conwy and
Gwynedd, which have the second and third highest number of cases of breast
cancer in North Wales, the highest standardised rates of breast cancer incidence,
the highest mortality (both in overall numbers and standardised rates). Flintshire also
has high relative need for service provision, as it has the highest absolute number of
breast cancers and the third highest number of deaths from the disease.
The analysis of hospital activity data for breast cancer has yielded interesting results.
Admission rates in North Wales were about half those in Mid & West Wales and less
than one third those in South-East Wales; within North Wales, rates were highest in
Denbighshire and lowest in Anglesey. Rates of bed use were highest in Gwynedd
and lowest in Wrexham; rates in North Wales were less than those in Mid & West
Wales but greater than those in South-East Wales. Average length of stay was
highest in Anglesey, lowest in Wrexham, and North Wales rates were higher than
those in Mid & West Wales and significantly higher than in South-East Wales.
However, it should be noted that the significant differences in admission rates, rates
of bed use and average length of stay between South-East Wales and the other two
regions may be due to differences in data collection (including procedural coding)
and require further investigation.
Lifestyle and risk behaviour remains an important issue to address across the North
Wales population. For example, levels of alcohol consumption are highest in
Flintshire, consumption of fruit and vegetables are lowest in Wrexham, physical
activity levels are lowest in Flintshire and levels of overweight of obesity are highest
in Flintshire. All these factors are amenable to primary prevention. The North Wales
health community in collaboration with key partners need to work hard to improve the
understanding of risk factors and lifestyle behaviour in the North Wales population.
1.4 Current breast care service provided to North Wales
The current breast care service to North Wales residents is provided by North West
Wales NHS Trust (NWWT) via Ysbyty Gwynedd (YG) and Llandudno Hospital sites,
North Wales NHS Trust through Ysbyty Glan Clwyd (YGC) and Wrexham Maelor
Hospitals and the Countess of Chester Hospital (CoCH). Breast screening is
provided by Breast Test Wales, a national screening service. Whiston Hospital
Plastic Surgical Unit provides a tertiary referral centre for breast plastic surgery.
Breast Test Wales provides a high quality breast screening service with a high
Standardised Detection Ratio for breast cancer from its two static centres in
Llandudno and Wrexham, as well as three mobile units. Breast Test Wales
Author: Dr Rob Atenstaedt,
Dr Julia Williams, Mr Andrew Jones
Version: 5
Date: 5/12/08
Status: Final
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Rapid Review of Breast Care Services in North Wales
undertake weekly independent MDT activity in relation to patients receiving
screening services.
In 2006, North West Wales NHS Trust had the highest number of referrals for North
Wales patients with breast cancer, followed by Wrexham Maelor and Ysbyty Glan
Clwyd. North West Wales NHS Trust also diagnosed the greatest number of breast
cancers.
In terms of case volumes, all Trusts saw more than 100 new breast cancers per year
and most see more than 150. Currently, all Trusts hold weekly MDT meetings, MDT
core membership is compliant and attendance is good for all Units. All Trusts have
the full range of extended team members (although virtually none of these report that
they routinely attend MDT meetings). All the breast cancer teams are compliant with
the cancer waiting times.
1.5 The Breast Care Patient Journey
Guidance that has been produced around breast cancer care includes that from
EUSOMA, NICE 2002, Welsh Assembly Government, BASO, European Union and
recent draft NICE Guidance.
Population based mammographic screening is effective in reducing mortality from
breast cancer by up to 30% in women aged 50 to 69. The cost-effectiveness of
mammographic screening is influenced by a range of factors. Guidance is that breast
screening programmes should be based within or closely associated with a
recognised Breast Unit, which is already the case in North Wales.
Women with a first degree relative with breast cancer have a three-fold increased
risk of developing the disease. These women should be provided services according
to NICE guidance, which WAG has recently endorsed.
Consensus supports a triple assessment approach in the assessment of
symptomatic women, which all Trusts serving North Wales residents provide.
The role of MRI is under evaluation, although it has an established place in the
investigation of implant dysfunction, recurrent or multifocal malignancy. NICE has
recommended that women at increased risk of breast cancer as a result of their
family history be offered annual MRI scanning. MRI is available on-site at all Units
except for Llandudno Hospital.
Recent draft NICE guidelines suggest that patients with early invasive breast cancer
should be offered DXA scanning in certain circumstances. The DXA scanner for
North Wales is based at Llandudno Hospital.
A Breast Unit must advise and where necessary treat women with benign breast
disease. Treatment of DCIS is by mastectomy or breast conservation therapy. Two
equally efficacious treatments for Stage 1 and Stage 2 breast cancer are modified
radical mastectomy or breast conservation therapy, followed by radiotherapy.
Pathological staging should be done to direct decisions on adjuvant therapy. Sentinel
Author: Dr Rob Atenstaedt,
Dr Julia Williams, Mr Andrew Jones
Version: 5
Date: 5/12/08
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Lymph Node Biopsy with pre-operative lymphoscintogram is a safe and effective
alternative to axillary dissection in trained hands. It is provided at all Breast Centres
except for Llandudno Hospital and Countess of Chester (which has plans to
introduce in 2009).
Evidence indicates that immediate breast reconstruction does not adversely affect
breast cancer outcome and has economic benefits, produces better results than
delayed reconstruction and reduces the psychological morbidity associated with
mastectomy. Guidance is that breast reconstruction should be offered to women at
the initial surgical operation and that an oncoplastic breast service should normally
be on site and constitute a core component of the MDT. This does not occur
throughout the current service provided to North Wales residents.
Routine follow up of women with treated breast cancer should be by routine physical
examination and yearly mammography; recent draft NICE guidelines have
suggested yearly mammography until age 70. A specialist palliative service should
be available for referral of cases of breast cancer.
Up to one third of women with breast cancer will suffer from psychological morbidity.
Psychological support should be available at every stage to help patients and their
families cope with the effects of the disease and a breast care nurse should be
available for support and counselling.
At every stage of the patient journey, individuals should be offered clear, objective,
full and prompt information in both verbal and written form and members of the
breast team should have special training in communication and counselling skills.
Local networks and voluntary organisations need to be engaged in this process.
1.6 Organisation of Breast Care Services
Guidance recommends that MDT meetings are held by the Breast Unit at least
weekly, which occurs in North Wales.
Recommendations exist around appropriate staffing of breast units. Each breast Unit
should have at least two consultant surgeons specially trained in breast disease, for
example, which is the case in North Wales.
The evidence base in relation to rural and remote communities shows that there is a
decline in access to services with increasing distance from medical care, and poorer
health outcomes of remove rural residents. There is little direct evidence around the
geographical location of breast units.
Breast Units should have appropriate facilities for diagnosis, treatment and follow-up.
There should be rapid access facilities for bone scanning and other imaging,
including MRI. Attention to be paid to patient privacy, with single sex wards or bays.
Author: Dr Rob Atenstaedt,
Dr Julia Williams, Mr Andrew Jones
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Date: 5/12/08
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Specialist and hospital caseload and/or specialisation have been shown to be
associated with improved cancer survival. It is recommended that Breast Units
should see at least 100-150 new case of breast cancer per annum and breast
surgeons should see at least 30-50 new cases of breast cancer per annum, and no
more than 150. These recommendations are likely to be fulfilled by the current
service.
Each primary care team should have at least one practitioner who has had specific
training in breast examination. There should be rapid referral of patients from primary
care to a Breast Unit.
Studies have shown benefits of one-stop clinics for breast cancer, although new
technology is making it difficult for patients to be fully assessed in one visit. Patients
should be fully assessed in three visits or less. It is our understanding that North
Wales patients currently have access to one-stop clinics at all Units.
There is good evidence that ambulatory breast surgery can be both safe and
effective, but it is not currently provided in North Wales.
There should be continuity of care and care pathways and referral guidelines should
be used in breast care services.
1.7 Summary of Service Gaps Identified
Comparing the service provided to North Wales residents with evidence and
guidance, it can be seen that the service provided is generally of high quality. All
Trusts are broadly compliant with the national breast cancer standards, EUSOMA
guidelines, NICE Improving Outcomes in Breast Cancer 2002, and BASO
Guidelines.
No hospital, particularly Llandudno Hospital, currently provides all the elements of a
modern breast care service. A particular gap for all Trusts is access to an on-site
comprehensive reconstructive/oncoplastic service. In addition, access to MRI is not
available at Llandudno Hospital (which does, however, have DXA scanning
available). Sentinel Node Biopsy service with Lymphoscintogram is not currently
available in Llandudno Hospital and Countess of Chester (although the latter plans to
introduce this in 2009). HDU/ITU services are currently provided only at the three
main acute hospital sites across North Wales.
1.8 Options for a new service model
Options for a new service model for breast care services need to consider the main
types of breast unit described and recommended activity levels. A range of options
involving the use of up to four Specialist Breast Units and three Diagnostic Breast
Assessment Units for the North Wales population are provided, based on a series of
assumptions. It should be noted that these options are not comprehensive and there
Author: Dr Rob Atenstaedt,
Dr Julia Williams, Mr Andrew Jones
Version: 5
Date: 5/12/08
Status: Final
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are other ways in which breast care services could be organised e.g. by performing
diagnosis and routine surgery in one unit, but more complicated surgery in another.
1.9 Recommendations
Recommendations given are as follows:
1/ A detailed option appraisal for delivery of breast care services is undertaken
based on the findings of this rapid review. This should have regard to appropriate
criteria (including the specific needs of a national breast screening programme
delivered by Breast Test Wales) and wider consideration of the provision of general
health care services across North Wales.
2/ As part of this process existing gaps in service provision should be considered
including:
a) further development of a breast reconstruction/oncoplastic service
based in North Wales.
b) introduction of ambulatory breast surgery for North Wales residents.
3) The North Wales health community, with its partners, should seek to:
a) maximise the appropriate uptake of breast screening services
b) actively promote the prevention of disease by working in collaboration to
address lifestyle/ risk behaviour, promote health and tackle inequalities in
health in the North Wales population.
Author: Dr Rob Atenstaedt,
Dr Julia Williams, Mr Andrew Jones
Version: 5
Date: 5/12/08
Status: Final
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Rapid Review of Breast Care Services in North Wales
2.0 Definition and Scope
2.1 Background
Breast disease is a major public health problem in Wales as it is a significant cause
of morbidity and mortality. In addition, breast care services consume substantial
resources for NHS Wales.
A review of breast surgery services at Llandudno Hospital (limited to services
provided in Mid and West areas of North Wales) by Holcombe and Raynor (1) and a
review of the future role of Llandudno Hospital by Burns (2) were both undertaken in
2007.
The Holcombe and Raynor review (1) concluded that Llandudno should not provide
breast surgery services. However, the Welsh Health Minister has recently stated that
‘the current breast care service should remain at Llandudno for the foreseeable
future whilst further work and advice is provided on a model of breast care services
in North Wales’.
The North Wales Cancer Network was asked to lead on a project to develop an
agreed model for breast care services for all of North Wales and the consequent
implications for Llandudno Hospital. The Cancer Network requested the National
Public Health Service for Wales (NPHS) to assist in this project (Appendix 1),
particularly in phases 1 and 2.
Accountability for the overall Project rests with the North Wales Planning Forum and
Conwy Local Health Board (LHB) and the Network officers and the stakeholder staff
are contributing to this piece of work on behalf of the these bodies.
2.2. Aim
The aim of the NPHS project is to identify the option(s) for optimal configuration of
breast care services for North Wales residents to ensure that patients have the
opportunity to access high quality breast care services.
2.3. Objectives
1/ To determine the burden of breast disease in North Wales and the need for breast
care services for the resident population
2/ To review the current breast care service provided to the residents of North Wales
3/ To determine what elements a high quality breast care service should provide and
to identify any gaps in the current service.
4/ To describe the option(s) for a new service model to facilitate North Wales Cancer
Network to develop a plan to address delivery of a preferred clinical model and
address any unmet need and inequity of access to breast care services
Author: Dr Rob Atenstaedt,
Dr Julia Williams, Mr Andrew Jones
Version: 5
Date: 5/12/08
Status: Final
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2.4 Methodology
The NPHS methodology for conducting service reviews/developing a service design
was followed (3,4).
2.5 Scope
All breast disease to be included including benign and malignant pathways and
include all services from prevention, screening, diagnosis, treatment and follow-up
and all related services including oncoplastic breast surgery, breast radiology and
pathology. While the symptomatic services in the review are all part of the North
Wales health community, recognition is given to the fact that Breast Test Wales
(BTW) is also an all-Wales organisation, working to all-Wales protocols. Male breast
cancer is rare, accounting for less than 1% of new diagnoses of breast cancer (5).
Treatment strategies reflect those recommended for women (6). For this reason, this
review will not consider male breast cancer further. Specific recommendations on
radiotherapy, chemotherapy and the North Wales Cancer Treatment Centre will not
be made.
2.6 Limitations
With the short timescale available for production of this review, there has to be a
balance between timeliness and rigour and so a pragmatic approach has been
followed, with a rapid review building on data presented in the previous report into
breast surgery by Holcombe and Raynor (1). For this reason, most data has been
limited to 2006. For the healthcare needs assessment, only epidemiological, rather
than corporate and comparative methods, have been utilised. It has not been
possible to carry out a rigorous systematic review, to review all the literature in
relation to key areas or to carry out site visits.
Author: Dr Rob Atenstaedt,
Dr Julia Williams, Mr Andrew Jones
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3.0 Healthcare Needs Assessment
Healthcare needs assessment is defined as “the systematic approach to ensuring
that the health service uses its resources to improve the health of the population in
the most efficient way” (7). It is usually accepted that this occurs within finite
resources (8). If healthcare needs are to be identified, then an effective intervention
should be available to meet these needs and improve health. There will be no benefit
from an intervention that is not effective (7). Healthcare needs assessment must
balance clinical, ethical, and economic considerations of need – that is, what should
be done, what can be done, and what can be afforded. The approach also provides
a method of monitoring and promoting equity in the provision and use of health
services and addressing inequalities in health (9,10). Equitable access to effective
services based on need has been emphasised in the Welsh NHS Plan (11). In this
report, healthcare need will be taken to be the population’s ability to benefit from
health care i.e. preventive, diagnostic or treatment services (12). Healthcare needs
assessment involves looking at the demographics and other factors of the population
whose needs are being addressed, outlining the ‘burden of disease’ in terms of
morbidity and mortality (epidemiological), comparing service provision in different
areas (comparative) and eliciting information from professionals, pressure groups
and the public (corporate). Only an epidemiological needs assessment has been
used in this review for the reasons noted in 2.6 above.
3.1 Population (13)
3.1.1 Demographics
This review focuses on the needs of the population of North Wales, a geographical
area of approximately 2,500 square miles. There are six unitary authorities within this
region - Anglesey, Gwynedd, Conwy, Denbighshire, Flintshire and Wrexham, which
are coterminous with the LHBs. Figure 1 shows the region.
Author: Dr Rob Atenstaedt,
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Figure 1: North Wales
In 2003, the population of North Wales was 670,800. Flintshire in the North East has
the largest population of 149,400 and Anglesey in the North West has the smallest
population, 68,400. Table 1 shows the resident population by Unitary Authority Area:
Table 1: Resident population of North Wales by Unitary Authority Area (2003
mid-year estimates)
All Persons
Males
Females
Anglesey
68,400
33,200
35,200
Gwynedd
117,500
56,700
60,800
Conwy
110,900
53,000
57,900
Denbighshire
94,900
45,500
49,400
Flintshire
149,400
73,300
76,100
Wrexham
129,700
63,500
66,200
North Wales
670,800
325,200
345,600
Source: Office for National Statistics via NPHS HIAT
Table 2 shows the age structure of North Wales by Unitary Authority.
Table 2: Age structure of North Wales by Unitary Authority (2003 mid-year
estimates)
0-4
5-15
16-24
25-44
45-65
65-74
Anglesey
3600
8500
7700
16400
19200
7000
Gwynedd
6500
14500
15200
28200
30400
11700
Conwy
5400
13300
11400
26000
29100
12900
Denbighshire
5000
11900
10300
23300
25000
9500
Flintshire
8400
19400
17500
42100
39000
12600
Wrexham
7300
16200
16500
35600
33300
10800
North Wales
36200
92600
69800
171900 175900
64500
Source: Office for National Statistics via NPHS HIAT
Author: Dr Rob Atenstaedt,
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75+
6200
10900
12900
9700
10300
10000
59900
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Rapid Review of Breast Care Services in North Wales
18.5% of the resident population of North Wales is aged 65 and over. This is slightly
higher than the Welsh average of 17.5%. Conwy and Denbighshire have the highest
proportions of people aged 65 years and over in Wales, 23% and 20% respectively.
Conwy and Denbighshire also have the highest proportions of people aged 85 years
and over in Wales, 3.3% and 2.8%.
The population of North Wales is predicted to increase to almost 700,000 by 2028
(14). In 2028, young people will account for a smaller percentage of the total
population than in 2005, while older people will account for a higher proportion
Appendix 2 provides estimated population projections for North Wales for 2003 –
2028 (15).
3.1.2 Population density
Population density varies across North Wales, with Wrexham and Flintshire being
the most densely populated areas. Denbighshire, Conwy and Anglesey are more
sparsely populated and Gwynedd has the most sparsely distributed population in
North Wales. Table 3 shows the population density across the region.
Table 3: Population Density, North Wales
UA Area
Population per km2
Anglesey
95
Conwy
98
Denbighshire
113
Flintshire
257
Gwynedd
46
Wrexham
341
Source: Office for National Statistics, 2005
North Wales has 62 areas which are classed as ‘urban’ (that is, an area with a
minimum population of 1,500). 40 of these areas have populations of less than 5,000
people and 14 areas have populations of 10,000 people or more (Table 4):
Author: Dr Rob Atenstaedt,
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Table 4: Main urban areas in North Wales
Name
UA Area
Resident population
Holyhead
Anglesey
11237
Bangor
Gwynedd
15280
Llandudno
Conwy
14872
Colwyn Bay
Conwy
30269
Abergele
Conwy
17574
Rhyl
Denbighshire
25390
Prestatyn
Denbighshire
18496
Shotton (inc. Hawarden)
Flintshire
24751
Connah’s Quay
Flintshire
16526
Buckley
Flintshire
18268
Flint
Flintshire
11936
Brymbo/Gwersyllt
Wrexham
17912
Rhosllanerchrugog
Wrexham
13246
Wrexham,
Wrexham
42576
Source: Office for National Statistics, 2001 Census
3.1.3 Transport Networks
The key road transport links in North Wales are the A55 Expressway (which also
acts as the North Wales section of Euro Route 22), the A5, A483, A487 and A470.
The A55 Expressway (which has four road tunnels) experiences the highest volume
of traffic, which increases significantly during the summer months owing to the flow
of tourists into the region.
Car ownership can have significant advantages to an individual and household.
Owning a car can improve access to services such as healthcare, employment and
leisure activities. Conwy and Wrexham have the highest proportion of households in
North Wales with no car or van, 24%, although they are below the average for
Wales, 26%. Figure 2 shows the approximate road travel time to the nearest major
hospital and illustrates that there are large areas of North Wales where travel time to
a major hospital is an issue.
Author: Dr Rob Atenstaedt,
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Figure 2: Approximate travel time to nearest major hospital
Source: Designed for North Wales (16)
3.1.4 Ethnicity
Race and ethnicity are important issues reflecting the need for and uptake of health
services. Less than 1.2% of the population of North Wales belongs to a Black,
Minority or Ethnic Community (BME). Most BME communities are concentrated
around the Bangor, Rhyl and Wrexham areas.
3.1.5 Socio-economic deprivation
Despite improvements in health, the gap between the least and most deprived
appears to be widening at a national level. A key challenge for organisations is to
ensure that sufficient focus is placed on the longer term aims of tackling health
inequalities. Across Wales, electoral wards have been grouped from worst to best
into fifths (quintiles). On an all Wales basis, 705,118 people are recorded as
residing within the most deprived wards. 122,181 people are recorded as living
within such wards which are located within North Wales (i.e. approx 17% of the total
population living within the most deprived wards in Wales). Table 5 shows that the
highest percentage of people living in the most deprived wards in the region are in
Gwynedd and Wrexham.
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Table 5: Percentage of people living in most deprived wards in North Wales
Number
%
Gwynedd
32,900
28
Isle of Anglesey
11,622
17
Denbighshire
12.335
13
Conwy
18,849
17
Wrexham
28,544
22
Flintshire
17,931
12
Source: ONS 2001 Census
3.1.6 Health Services in North Wales
North Wales has a total of 123 GP Practices, most of which are in Flintshire and
Wrexham. Anglesey has the least number of GP Practices. This is shown in Table 6.
Table 6: Number of GP Practices in North Wales by UA Area, 2004
Anglesey
11
Gwynedd
27
Conwy
19
Denbighshire
16
Flintshire
26
Wrexham
24
North Wales
123
Source: Welsh Assembly Government 2005
There are 42 hospitals in North Wales. Three of these – Ysbyty Gwynedd (Bangor),
Ysbyty Glan Clwyd (Bodelwyddan) and Ysbyty Maelor (Wrexham) – are major acute
hospitals, and a further two – Ysbyty Llandudno and Ysbyty Abergele – are acute
hospitals.
Figure 3 shows the location of hospitals across North Wales.
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Figure 3: Location of hospitals across North Wales (NB Lluesty Community
Hospital is now closed)
In July 2008, Conwy & Denbighshire NHS Trust and North East Wales NHS Trust
combined to form the North Wales NHS Trust. In general, the North West Wales
NHS Trust serves the Unitary Authority areas of Gwynedd, Anglesey and Conwy,
and North Wales NHS Trust serves the Unitary Authority areas of Conwy,
Denbighshire, Flintshire and Wrexham. Whilst these are the main secondary care
services provides in the region, some people access secondary care services
elsewhere (such as in Powys, Ceredigion and Cheshire) depending on their
geographical location. North Wales has an average of 2,896 beds available on a
daily basis, of which 1,841 are dedicated for acute services (Table 7).
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Table 7: Average Daily Beds in North Wales by NHS Trust, 2007/08
North West
Conwy &
North East
Wales NHS
Denbighshire
Wales NHS
Trust
NHS Trust*
Trust**
Acute
661
540
640
Maternity
33
38
38
Geriatrics
223
185
106
Non917
762
784
psychiatrics
Psychiatrics
215
136
82
All Beds
1132
898
866
North
Wales
1841
109
514
2463
433
2896
Source: Welsh Assembly Government
* now Central Division of North Wales NHS Trust
** now Eastern Division of North Wales NHS Trust
The Northern Division of BTW serves the population of North Wales, as well as the
county of Powys.
Key Messages:





The population of North Wales is approximately 670,000 and likely to
grow to almost 700,000 by 2028.
The demography of North Wales is predicted to change over the next
20-30 years with a large growth in the number of older people.
The population is scattered between large concentrations of people
in and around the region’s key urban centres, coastal resorts and
rural market towns and smaller concentrations in and around rural
villages, hamlets and settlements, which can make geographical
access to health services an issue.
Due to a relatively poorly developed road infrastructure in North
Wales, travel time to hospitals in North Wales can be an issue for
remote rural communities.
Tackling health inequalities is a key issue, with almost one fifth of the
population living within the most deprived wards in Wales located in
North Wales. Gwynedd and Wrexham have the highest proportion of
its population living in the most deprived wards within the region.
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3.2 Epidemiology of Breast Diseases
3.2.1 Definition
Benign breast disease
It has been estimated that for every case of breast cancer there are seven or eight
new referrals of women with other breast problems (17,18). In fact, about 85% of
breast lumps are benign (non-cancerous).
Types of breast lump include (19):





Fibrocystic breast disease (fibroadenosis) - a group of benign conditions
affecting the breast that can cause enlargement, pain tenderness, and
lumpiness, particularly just before or during menstruation.
Fibroadenoma – a small tumour in the breast, which often develops in
adolescent women and those in their early 20s, but can occur at any age.
These lumps are benign and are not associated with an increased risk of
breast cancer.
Breast cyst – a fluid filled lump. Breast cysts are most common in premenopausal women, aged 40-55, and those who take HRT at any age. Cysts
vary in size, they can be very tiny, or they can grow up to several centimetres
in diameter. Single or multiple cysts can occur in one or both breasts. Cysts
often cause no symptoms, but some women may experience pain, particularly
if the cyst increases in size during the menstrual cycle.
Fat necrosis – a hard irregular lump, often caused by trauma. They usually
disappear spontaneously.
Lipoma - a fatty growth that causes a lump that changes the shape of the
breast. It requires no treatment.
Breast Cancer
Breast cancer is the most common type of cancer among women in the UK. About
45,000 cases are diagnosed every year, 2500 of which are in Wales.
There are a number of different types of breast cancer, which can develop in
different parts of the breast. The most common type is ductal breast cancer, which
accounts for about 80% of all cases. Less common types include lobular breast
cancer, inflammatory breast cancer, and Paget's disease of the breast.
Women with breast cancer can also be subdivided into one of three subgroups in
terms of treatment (20)

Ductal carcinoma in situ (DCIS), Stage 0 – this may present as a palpable
mass or an asymptomatic mammographic abnormality. It is distinguished from
invasive disease by the absence of stromal invasion on histiological
examination.
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Early breast cancer, Stages 1 and II - confined to the breast tissue with or
without local spread to axillary lymph nodes on the same side as the tumour.
These local cancers are amenable to surgical intervention.
Advanced breast cancer, Staged III and IV - includes locally advanced
disease and distant metastases. Locally advanced disease may invade the
chest wall and/or overlying skin and involved lymph notes may be fixed to or
invade other structures. Distant metastases can occur.
3.2.2 Incidence, Mortality and Survival
Benign Breast Disease
Estimating the incidence of benign breast disease in the population is very difficult as
it is not a life-threatening condition and so does not always come to medical
attention. The incidence can therefore only be approximated by comparing the
prevalence rate of benign breast disease obtained from autopsy studies with the
cumulative incidence rates from cohort studies, although this is likely to be an
underestimate as many benign conditions resolve after the menopause. This method
has been used by Goehring and Morabia (21) to calculate age specific rates per
1000 women years for fibrocystic breast disease and fibroadenoma, as shown in
Figure 4.
Figure 4: Age specific incidence rates per 1,000 women years for fibrocystic
breast disease and fibroadenoma
Figure 4 shows that the incidence rate per 1000 women-years of fibrocystic breast
disease increases progressively from 137 at ages 25-29 years to 411 at ages 40-44
years and to 387 at ages 45-49 years, and then decreases regularly. The incidence
of fibroadenoma peaks at 115 at ages 20-24 years, decreases regularly until the
ages of 45-49 years and remains close to 5 for women of older ages. The
researchers also calculated that the cumulative incidence of biopsy proven
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fibrocystic breast disease before the age of 65 is 8.8% and the cumulative incidence
of fibroadenoma is 2.2%.
Breast Cancer (19)
In 2006, there were about 12,000 deaths from breast cancer in the UK - 99% of
these were in women and only 1% in men (22-24). Breast cancer accounts for
around 17% of female deaths from cancer in the UK and was the most common
cause of death from cancer in women until 1998; since then there have been more
deaths from lung cancer.
Relation with Age
Although very few cases of breast cancer occur in women in their teens or early 20s,
breast cancer is the most commonly diagnosed cancer in women under 35. Breast
cancer incidence rates continue to increase with age, with the greatest rate of
increase prior to the menopause and more than 80% of breast cancer cases occur in
women over 50 years old.
Geographical variation in incidence and mortality
Worldwide, more than a million women are diagnosed with breast cancer every year.
The highest rates of breast cancer incidence are in the developed world and the
lowest rates in Africa and Asia. In Europe, the lowest rates are in Romania and
Latvia and the highest are in northern and western Europe. Migrants from low to high
risk countries acquire the risk of the host country within two generations. Kruijshaar
et al compared the burden of breast cancer (expressed in Disability Adjusted Life
Years) for six European countries using epidemiological data from 1996 (25). They
found that Denmark and the Netherlands lost the greatest number of DALYs (1100
DALYs per 100,000 women). They were followed by England and Wales (87% of the
Danish burden), France (72%), Sweden (68%) and Spain (67%). 70 to 80% of the
burden was caused by mortality.
Temporal trends in incidence and mortality
There has been a steady rise in breast cancer incidence for many years in the
developed world. It is thought that this is due to changes in the distribution of known
risk factors for breast cancer e.g. late age at first pregnancy, early menarchy and
prolonged use of oral contraceptive (26). However, breast cancer mortality rates in
the UK have fallen dramatically since 1989 when about 16,000 women died from the
disease compared with 12,000 in 2006. Over the same period the breast cancer agestandardised death rates have fallen by 34% from 42 to 28 per 100,000 women. This
decline is likely to have several different causes including screening, increasing
specialisation of care and the widespread adoption of tamoxifen treatment since
1992.
Survival
The relative five-year survival rate for women diagnosed in England and Wales in
2001-2003 was 80%, compared with 52% for women diagnosed in 1971-1975. The
relative survival for screen detected breast cancer is 96.5% at 5 years and 86.3% at
15 years (27). The largest improvements in five-year survival have been for women
aged 50-69 years.
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In general, the later the stage of breast cancer at diagnosis, the lower the survival
rate. In addition, women with breast cancer who live in affluent areas have better
survival rates than women in deprived areas (28,29). The most recent data for
England and Wales has shown a statistically significant deprivation gap difference of
5.8% in five-year survival for women diagnosed between 1996 and 1999.
3.2.3 Aetiology, Risk Factors and Prevention
Benign breast disease (19)
The most common cause of benign breast lumps is hormonal changes in a woman's
body. These changes can occur during adolescence or the menopause, but are most
often associated with the monthly menstrual cycle. Breast pain that is not associated
with menstruation is sometimes known as non-cyclic pain. Other causes of benign
lumps and pain in the breast can include breast inflammation (mastitis), nipple
discharge, dilated milk ducts, and trauma to the breast due to injury or scarring from
past surgical procedures.
Breast Cancer (30)
Most of the known risk factors for breast cancer relate to a woman’s reproductive
history including old age, early menarche, late first pregnancy, low parity, and late
menopause; endogenous hormones, both oestrogens and androgens also have a
role. Some types of benign breast disease also increase the risk of developing
breast cancer. Evidence has shown that none of these risk factors are currently
amenable to primary prevention (31). Use of oral contraceptives and HRT have also
been linked to increased risk of breast cancer (32). Alcohol consumption is
associated with an increased risk of the disease, but tobacco smoking does not
seem to augment the risk (33). Avoidance of obesity may decrease the risk of
postmenopausal breast cancer, and switching from a high-fat and low vegetable diet
to a lower-fact, higher vegetable diet may lead to a reduced risk. This is thought to
be linked to the amount of oestrogen in the body, as being overweight, or obese,
causes more oestrogen to be produced. Women who breastfeed are statistically less
likely to develop breast cancer than those who do not and this might be due to the
fact that women do not ovulate as regularly while they are breastfeeding, and their
oestrogen levels remain more stable.
Studies of migrant workers have suggested that differences in breast cancer
incidence between countries are social and environmental, rather than genetic in
origin; only about 5% of breast cancer cases are due to inheritance of dominant
genes such as BRCA1 and BRCA2 (34). A third gene, TP53, has recently been
linked with an increased risk of breast cancer (19).
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Key Messages:







Breast cancer is the most common cancer in women in the UK with
45,000 cases diagnosed per annum, 2,500 of which are in Wales.
For every case of breast cancer, there are 7-8 referrals for women
with benign breast disease.
Estimating the incidence rate of benign breast disease in the
population is difficult as many cases do not present to medical
attention. The incidence can be approximated by comparing the
prevalence rate of benign breast disease obtained from autopsy
studies with the cumulative incidence rates from cohort studies,
although this is likely to be an underestimate.
80% of breast cancer cases occur in women over age 50. There has
been a steady rise in the incidence of breast cancer in the developed
world over many years, though mortality from the disease has fallen
since 1989.
Survival from breast cancer has improved significantly over the last
three decades in the UK. Women who live in more affluent areas have
better survival.
Risk factors for breast cancer include old age, early menarche, late
first pregnancy, low parity, and late menopause, which are not
amenable to primary prevention
Alcohol consumption is associated with an increased risk of breast
cancer, and avoidance of obesity after menopause may decrease the
risk of breast cancer; women who breastfeed are less likely to
develop breast cancer. Only 5% of breast cancers are of genetic
origin.
3.3 Incidence, Mortality and Survival: North Wales
3.3.1 Data
A variety of statistics are used to quantify the burden (occurrence and outcome) of
cancer generally and of breast cancer specifically. When undertaking any review of
cancer services, understanding these statistics is vital (35). Two core statistics are
the cancer incidence rate and the cancer mortality rate, which provide estimates of
the average risk of acquiring and of dying from the disease respectively. Kruijshaar
et al (25) concluded that to compare the burden of breast cancer, mortality rates
provide sufficient information. However, this rapid review includes data on incidence,
mortality and survival to describe the impact of breast cancer on the North Wales
population.
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The Welsh Cancer Intelligence & Surveillance Unit (WCISU) collects information on
all new cancers occurring in the population and these are used to estimate incidence
rates and mortality rates for the North Wales population. Cancer incidence and
mortality increases with age and in order to compare different populations, it is
necessary to standardise for this factor. This process is called ‘standardisation’ and
the measure derived is termed the European age standardised incidence rate
(EASR).
Population based survival rates are derived from matching death registrations with
cancer registrations and are expressed as a proportion of patients alive at some
defined point subsequent to the date of diagnosis. Observed survival is the
probability of survival at a given time since diagnosis, irrespective of cause of death.
It is usually expressed as the percentage alive at the given time point, e.g. 1 year, 5
years etc. since diagnosis. Problems with this method arise if comparisons are to be
made between populations with different age distributions. Observed survival is
likely to be lower in an older population as they are more likely to die not just of the
cancer, but also of other causes. Relative survival is the most widely used method in
population studies. It is the ratio of the survival observed in the group of cancer
patients to the survival that would be expected if they were subject to the same
overall mortality rates by age, sex and calendar period as the general population. A
relative survival rate of 100% for a given period would imply that the cancer patients
had the same survival (or death rates) as the general population, not that they all
survived. The expected probabilities are obtained from life tables for Wales that
provide the life expectancy of persons for a given year by age and sex. The
problems arising with crude survival are therefore overcome. This method enables
one to measure variations in cancer survival (or its complement, mortality)
independently of variations in expected (background) mortality associated with age,
geographic region, deprivation and calendar time. However, cancer survival is a
broad indicator and differences may be due to a range of factors, of which quality of
treatment is only one. Differences in cancer survival between geographical areas
should therefore be the origin of further enquiry, not the basis for simplistic
conclusions about the efficacy of cancer treatment.
3.3.2 Methodology for Cancer Incidence Projections (36)
Cancer incidence projections were calculated by WCISU and their detailed
methodology is given in Appendix 3. Projections of incidence figures into the future
should always be viewed with caution. There are a number of accepted methods of
calculation and each, whilst equally valid, will not give the same results. With the
projections obtained with the APC (Age-Period-Cohort) modelling, assumptions have
been made which may not necessarily hold. The predictions are not able to take into
account changes which occur outside of the range covered by the past data, such as
the effects of new drugs/treatments or environmental issues affecting birth cohorts
not included in the statistical analysis. For this reason, WCISU stress the importance
of reviewing these figures in context and alongside other information.
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3.3.3 Sources of Information
Table 8 summarises the sources of the information used for the healthcare needs
assessment:
Table 8: sources of information used in healthcare needs assessment
Topic
Source
Comment
Prevalence of risk factors for
WAG
Data derived from Welsh Health
breast disease
Survey 2005/7
Cumulative incidence of
benign breast conditions
Background
literature
Application of prevalence data
from study to North Wales midyear population estimates: 2006
Incidence and Mortality of
Breast Cancer
WCISU
Obtained from WCISU database
Past Trends in Incidence of
Breast Cancer
NPHS
Future trends in Incidence of
breast cancer
WCISU
See explanation of analysis
Survival from Breast Cancer
WCISU
See explanation of analysis
Hospital Admissions for Breast
Cancer
NPHS
Obtained from e-healthshow
from PEDW data
Other hospital activity data e.g.
bed use
NPHS
Obtained from e-healthshow
from PEDW data
Uptake of breast cancer
screening
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3.3.4 Prevalence of risk factors associated with breast disease (30)
Table 9 shows health related lifestyle age standardised statistics for adults by
Unitary Authority in Wales, 2003-2005, taken from the Welsh Health Survey. This
survey relies on a self-completed questionnaire and so the results reflect individual’s
understanding of their health rather than a clinical assessment of their medical
condition. The survey results are then weighted to take account of unequal selection
probabilities, and for differential non-response. The table shows that levels of alcohol
consumption are highest in Flintshire, consumption of fruit and vegetables are lowest
in Wrexham, physical activity levels are lowest in Flintshire and levels of overweight
and obesity are highest in Flintshire:
Table 9: Health related lifestyle (adults) by Unitary Authority, 2005-2007
Unitary Authority
Anglesey
Gwynedd
Conwy
Denbighshire
Flintshire
Wrexham
Wales
Smoking
23
24
24
28
25
26
25
Alcohol
Binge Consumption Physical Overweight
consumption drinking
of fruit &
activity
or obese
(b)
(c)
vegetables
(e)
(d)
31
34
28
35
39
34
36
15
17
15
19
19
18
19
45
47
45
42
44
41
44
33
35
29
34
30
36
30
52
52
51
52
56
54
56
Source: Welsh Health Survey
(a) Observed percentages are shown here, for age-standardised percentages see the Welsh Health Survey report. For details of
measures (eg units, portions) used please see note at beginning of chapter
(b) Usual alcohol consumption above daily guidelines
(c) Alcohol consumption on heaviest drink day in previous week above ‘binge drinking’ threshold
(d) Met guidelines the previous day
(e) Met guidelines the previous week
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3.3.5 Cumulative Incidence of Benign Breast Disease: North Wales
The cumulative incidence is the number or proportion of a group who experience the
onset of a health-related event during a specified time interval. If we apply Goehring
and Morabia (21) cumulative incidence figures of 8.8% for biopsy proven fibrocystic
breast disease and 2.2% for fibroadenoma to the population of North Wales under
the age of 65 (based on 2006 mid-year population estimates), we can estimate that
there are at least 25,000 women in North Wales under the age of 65 who will
develop a benign breast condition in their lifetime; the highest proportions of these
are in Flintshire and the lowest in Anglesey (Table10).
Table 10: Estimate of Benign Breast Disease in North Wales
LHB
Females
between 1565 (%)
No with Fibrocystic
Breast Disease
No with
Fibroadenomas
Anglesey
22,000 (10%)
1,936
484
Gwynedd
37,900 (17%)
3,335
834
Conwy
33,900 (15%)
2,983
746
Denbighshire
33,300 (15%)
2,930
733
Flintshire
49,700 (23%)
4,374
1093
Wrexham
43,200 (20%)
3,802
950
220,000
19,360
4840
North Wales
3.3.6 Hospital Admissions for Benign Neoplasm of the Breast
Table 11 and Figure 5 shows that the European aged standardised admission rates
for benign neoplasm of the female breast were highest in Gwynedd and lowest in
Anglesey in 2005-6. Table 11 also shows the great variability in admission rates
between 1999/2000 and 2005/6, likely due to small numbers, as very few benign
breast conditions lead to admission to hospital (less than 100 per year in North
Wales on average).
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Table 11: European age standardised admission rate for Benign neoplasm of
female breast (ICD 10 D24)
European age standardised rate per 100,000 female population
Benign
neoplasm of
the female
breast
99/00
00/01
01/02
02/03
03/04
04/05
05/06
Anglesey
14.6
22.4
32.2
25.3
27.1
30.9
3.6
Gwynedd
39.1
13.5
12
27.3
11.4
16.7
35.7
Conwy
33.1
34.3
35.1
21.5
13.8
12.6
34.1
Denbighshire
Flintshire
Wrexham
52.1
40.5
30
34.2
22.2
28
33.1
27.2
45.5
32.4
19
18.6
37.7
56.1
62.2
37.2
36.7
31.9
Source: PEDW as reported in ‘Statistical indicators’
Figure 5:
2005/2006 Benign Neoplasm of Female Breast
Data source: PEDW as reported in 'Statistical Indicators'
05/06
40
EASR per 100,000
35
30
25
20
15
10
5
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W
re
xh
am
hi
re
Fl
in
ts
gh
sh
ire
De
nb
i
y
Co
nw
G
wy
ne
dd
An
gl
es
ey
0
Status: Final
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33.1
28.8
29.3
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3.3.7 Incidence and Mortality from Breast Cancer: Wales
Table 12 compares the incidence rate of female breast cancer in UK home nations in
2005. This shows that the incidence rate in Wales at 122.2 is the second highest
after England, although less than the UK average.
Table 12: Number of new cases and rates of breast cancer, UK 2005
England
Wales
Scotland
N. Ireland
UK
250
12
20
5
287
Females
38,212
2,375
3,998
1,075
45,660
Persons
38,462
2,387
4,018
1,080
45,947
1.0
0.8
0.8
0.6
1.0
Females
148.6
156.8
151.5
122.1
148.5
Persons
76.2
80.8
78.9
62.6
76.3
0.6
0.8
Cases
Males
Crude rate per 100,000 population
Males
Age-standardised rate (European) per 100,000 population
Males
0.9
CI 95%
Females
0.6
0.8
1.0
123.2
0.3
0.7
1.0
122.2
0.4
1.0
119.8
0.1
1.2
0.7
110.1
0.9
122.5
CI 95% 122.0 124.4 117.3 127.1 116.1 123.5 103.5 116.7 121.4 123.6
Persons
64.9
CI 95%
64.2
64.5
64.5
65.5 61.9 67.0 62.5 66.5
Source: Cancer Research UK
58.6
55.1
62.1
64.7
64.1
65.3
Table 13 compares the mortality rates from breast cancer in the UK and home
nations in 2006. Wales had the second highest mortality rate from breast cancer in
the UK (28.5) after Scotland, although this was not significantly higher than the UK
average.
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Table 13: Number of deaths and mortality rates of breast cancer, UK 2006
England
Wales
Scotland
Deaths
Males
59
9
4
Females
10,243
673
1,108
Persons
10,302
682
1,112
Crude rate per 100,000 population
Males
0.2
0.6
0.2
Females
39.9
44.0
42.2
Persons
20.4
22.9
21.9
Age-standardised rate (European) per 100,000 population
Males
0.2
0.5
0.1
0.1
0.2
0.2
0.8
0.0
0.3
CI 95%
Females
27.5
28.5
28.6
27.0 28.0 26.3 30.7 26.9 30.3
CI 95%
Persons
15.0
15.6
15.9
14.7 15.3 14.5 16.8 15.0 16.8
CI 95%
Source: Cancer Research UK
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N. Ireland
UK
1
295
296
73
12,319
12,392
0.1
33.5
17.2
0.2
40.1
20.6
0.1
-0.1
27.0
23.9
14.8
13.1
0.2
0.2 0.2
27.7
27.2 28.1
15.1
14.8 15.4
0.4
30.0
16.5
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3.3.8 Incidence of Breast Cancer: North Wales
Table 14 shows that there were an average of 565 cases of breast cancer per year
in the period 1997-2006 and that the highest average number was in Flintshire,
closely followed by Conwy. The highest standardised incidence rates were in
Gwynedd, closely followed by Conwy. The overall incidence rate in North Wales was
higher than the Welsh average.
Table 14: Female Breast Cancer in North Wales, 1997-2006
INCIDENCE
LHB
Total cases
Average cases per year
EASR
Isle of Anglesey
558
56
115.16
Gwynedd
1049
105
130.04
Conwy
1112
111
128.24
Denbighshire
855
86
122.68
Flintshire
1143
114
124.77
Wrexham
935
94
110.98
North Wales
5652
565
122.53
All Wales
22479
2248
117.63
EASR - European Age Standardised Rate per 100,000 population
Source: WCISU
Figure 6 shows that the standardised incidence rates of breast cancer in Gwynedd
and Conwy were, in fact, significantly higher than the all Wales rate during this
period.
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Figure 6:
Registrations for cancer of the breast, females, all ages
by area of residence: 1997-2006
Low
Significantly low
Significantly high
High
Data source: Welsh Cancer Intelligence and Surveillance Unit
140
Welsh average = 117.6
European age standardardised rate
(per 100,000 population)
120
100
80
60
40
Gwynedd
Conwy
Flintshire
Monmouthshire
Powys
Denbighshire
Pembrokeshire
Ceredigion
Carmarthenshire
Merthyr Tydfil
Bridgend
Torfaen
Isle of Anglesey
Swansea
Caerphilly
Cardiff
The Vale of Glamorgan
Wrexham
Neath Port Talbot
Newport
Blaenau Gwent
0
Rhondda Cynon Taff
20
3.3.9 Mortality from Breast Cancer: North Wales
In terms of deaths from breast cancer, Table 15 shows that there were an average of
179 deaths from breast cancer per year in North Wales during 1997-2006, with the
greatest number in Conwy and Gwynedd. The highest standardised mortality rate
was recorded in Conwy, followed closely by Gwynedd and Denbighshire. The overall
mortality rate was higher in North Wales than the Welsh average.
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Table 15: Female Breast Cancer In North Wales, 1997-2006
MORTALITY
LHB
Total cases
Average cases per year
EASR
Anglesey
177
18
30.97
Gwynedd
335
34
33.65
Conwy
363
36
35.57
Denbighshire
276
28
33.50
Flintshire
323
32
31.70
Wrexham
319
32
32.00
North Wales
1793
179
32.93
All Wales
6962
696
31.11
EASR - European Age Standardised Rate per 100,000 population
Source: WCISU
Figure 7 again shows that incidence rates of breast cancer were highest in Conwy
and Gwynedd, and mortality was highest in the county of Conwy.
Figure 7:
European Age Standardised Rates per 100,000 population for
female breast cancer by Local Health Board in Wales, 1997-2006
Incidence
Mortality
106.83 – 111.47
111.47 – 116.11
116.11 – 120.76
120.76 – 125.40
125.40 – 130.04
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27.31 –
28.96 –
30.61 –
32.26 –
33.92 –
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28.96
30.61
32.26
33.92
35.57
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3.3.10 Trends in Incidence of Breast Cancer: North Wales
Past Trends
Figure 8 shows that the incidence of breast cancer has fluctuated in all counties in
North Wales over the last 10 years, but has increased overall in the period 19962005. In addition, the gap between the counties seems to have narrowed during this
period.
Figure 8:
150
140
130
120
110
100
90
Wales
Isle of Anglesey
Gwynedd
Conwy
05
-2
0
04
Flintshire
Wrexham
20
20
03
-2
0
03
Year
02
-2
0
02
20
01
-2
0
01
20
00
-2
0
00
99
-2
0
19
98
-1
9
19
97
-1
9
19
96
19
99
Denbighshire
98
Rate per 100,000
population
Registrations for Cancer of the Breast, Females,
all ages: 1996-2005
Source: Welsh Cancer Intelligence and Surveillance Unit
Future Trends
Table 16 illustrates that breast cancer incidence is predicted to increase in North
Wales from 2925 cases in 2001-5 to between 3375 (+15%) and 3990 (+36%) by
2016-2012 (subject to caveats), a potential large increase in need in the region.
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Table 16: Projections Of Female Breast Cancer Incidence In North Wales
Total cases
Projections*
Projections**
1976-1980
1705
1981-1985
1941
1986-1990
2079
1991-1995
2582
1996-2000
2555
2001-2005
2925
2006-2010
3230
3055
2011-2015
3590
3211
2016-2020
3990
3375
* Projections based on Age-Period-Drift model which was most significant model
** Projections based on Age-Period model
Source: WCISU
3.3.11 Survival from Breast Cancer: North Wales
Table 17 and Figure 9 gives 1 year, 3 year and 5 year survival rates for breast
cancer for the 1997-2001 cohort for North Wales counties. 5-year survival rates are
generally taken as the standard measure. This shows that the 5-year relative survival
rate was lowest in Gwynedd, Anglesey and Denbighshire, and highest in Flintshire.
In general, relative survival rates were slightly better in North Wales than the Welsh
average.
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Table 17: Survival for Female Breast Cancer in North Wales, 1997-2001 (Followed Up To 31st December 2006)
1 YEAR SURVIVAL
3 YEAR SURVIVAL
5 YEAR SURVIVAL
Observed
Relative
LHB
Survival
Relative Survival
Observed Survival
Relative Survival
Observed Survival
Survival
Anglesey
89.53
94.32
77.57
85.69
66.73
78.32
Gwynedd
89.19
93.42
77.19
85.18
66.57
78.06
Conwy
86.67
91.75
74.16
84.11
67.58
80.62
Denbighshire
83.34
88.02
70.96
80.51
63.62
78.34
Flintshire
89.83
93.32
78.34
84.80
71.78
81.73
Wrexham
89.26
93.38
77.17
85.93
68.06
80.83
N Wales
88.07
92.56
75.97
84.64
67.75
80.20
All Wales
88.27
92.01
76.18
84.06
67.89
79.52
Source: WCISU
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Figure 9:
Relative Survival for female breast cancer by Local Health Board in North
Wales, 1997-2001 (followed up to 31st December 2006)
Five year relative survival
One year relative survival
88.02 –
89.28 –
90.54 –
91.80 –
93.06 –
78.06 – 78.79
78.79 – 79.53
79.53 – 80.26
80.26 – 81.00
81.00 – 81.73
89.28
90.54
91.80
93.06
94.32
3.3.12 Hospital Activity Data for Breast Cancer: North Wales
Hospital admission rates are a poor proxy for population health need. Table 18 and
Figure 10 shows that the highest rate of hospital admissions for breast cancer in
North Wales was in Denbighshire, and lowest in Anglesey residents. Admission rates
in North Wales were about half those in Mid & West Wales and less than one third
those in South-East Wales. Rates of bed use, shown in Table 18 and Figure 11,
were highest in Gwynedd and lowest in Wrexham; rates in North Wales were less
than those in Mid & West Wales but greater than those in South-East Wales.
Average length of stay, shown in Table 18 and Figure 12, was highest in Anglesey,
lowest in Wrexham, and North Wales rates were higher than that in Mid & West
Wales and significantly higher than in South-East Wales. It should be noted that the
significant differences in admission rates, rates of bed use and average length of
stay between South-East Wales and the other two regions may well lie in differences
in data collection (such as procedural coding) and require further investigation.
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Table 18: Hospitalisation figures based on all admissions for Cancer of the
Female Breast
Female
Breast
Cancer
Anglesey
Gwynedd
Conwy
Denbighshire
Flintshire
Wrexham
North Wales
M & W Wales
SE Wales
Wales
No. of
Discharges:
Discharges
Rate/100k
131
371.4
402
659.8
377
652.5
440
884.3
608
798.6
390
584.9
2348
677.6
6688
1305.7
15349
2317.3
24385
1603.1
Source: eHealthShow
Beds
Used:
Rate/100k
3.7
5.6
4.2
5.4
3.5
2.0
4.0
5.1
2.4
3.7
Average Stay
3.7
3.1
2.4
2.2
1.6
1.3
2.2
1.4
0.4
0.8
Notes: For analysis by diagnosis, the disease code must occur in the principal diagnosis field in the first episode of the spell.
Provider spell rates are per 100,000 population of the grouping under consideration. Length of stay is given by the average
duration of the provider spells in the particular grouping. 'Beds' are the sum of bed-days (total duration of all provider spells in
grouping) divided by 365.
The daycase cleanse was removed from hopitalisation data from April 2007 as a directive from the Welsh Assembly
Government. From April 2006 all cancer patients having radiotheraphy treatment are coded as a spell in hospital, so are now
included in the number of daycases.The statistics are in the form of 'provider spells' and 'beds'. Bed-days for individuals, which
are used in the calculation of 'beds', have been truncated to 365 for diagnoses other than mental health where they are greater
than 365.
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Figure 10:
Hospital Discharge rate per 100,000 population for
female breast cancer
Data source: Ehealthshow
Discharges: Rate/100k
Rate per 100,000 population
1000
900
800
700
600
500
400
300
200
100
W
re
xh
am
in
ts
hi
re
Fl
De
nb
ig
hs
hi
re
Co
nw
y
yn
ed
d
G
w
Is
le
of
A
ng
le
se
y
0
Figure 11:
Beds used per 100,000 population for the treatment of
Cancer of the female breast
Data source: eHealthshow
Beds Used: Rate/100k
Beds used per 100,000 populations
6
5
4
3
2
1
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W
re
xh
am
in
ts
hi
re
Fl
Co
nw
y
yn
ed
d
G
w
De
nb
ig
hs
hi
re
Is
le
of
A
ng
le
se
y
0
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Figure 12:
Average length of stay for the treatment of Cancer of
the female breast
Data source: eHealthshow
Average Stay
4.0
3.5
3.0
Days
2.5
2.0
1.5
1.0
0.5
W
re
xh
am
in
ts
hi
re
Fl
Co
nw
y
yn
ed
d
G
w
De
nb
ig
hs
hi
re
Is
le
of
A
ng
le
se
y
0.0
3.3.13 Uptake of Breast Cancer Screening: North Wales
BTW screen about 20,000 women annually in North Wales. Uptake is the number of
women screened for breast cancer compared to those invited for screening. A
screening round is the number of times the service has called women for screening
in a locality. The majority of screening takes place on mobile units that move around
Wales, calling women registered with the local GP practices. BTW do not call women
based on their date of birth, hence the reason why women are not screened as soon
as they reach age 50. Because screening was rolled out across Wales, different
areas are on different rounds but Round 5 has been completed in all areas except
Flintshire. Parts of this county will not complete screening round 5 until January
2009. Throughout Wales, rural areas in general exhibit higher uptake than urban.
Table 19 and Figure 13 shows that the highest uptake rate for breast screening was
in Anglesey and the lowest in Denbighshire. North Wales screening uptake was
lower than the Welsh average.
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Table 19: Uptake of Breast Screening: North Wales LHB areas
LHB
Round 5 Uptake
Anglesey
76.5%
Conwy
72.8%
Denbighshire
71.9%
Flintshire
76.1% (round 4)
Gwynedd
73.8%
Wrexham
72.2%
North Wales
73.7%
Wales
75.2%
Source: Breast Test Wales
Figure 13: Uptake of Breast Screening North Wales.
Source: Breast Test Wales
Appendix 4 shows maps of breast screening uptake rates for individual LHBs by
electoral ward.
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Key Messages:
 In terms of risk factors for breast cancer, levels of alcohol
consumption are highest in Flintshire, consumption of fruit and
vegetables are lowest in Wrexham, physical activity levels are lowest
in Flintshire and levels of overweight/obesity are highest in Flintshire.
 Applying figures for cumulative incidence from the literature to the
North Wales population, it is estimated that there are at least 25,000
women under 65 in North Wales who will develop a benign breast
condition in their lifetime. The highest proportions of these are in
Flintshire and the lowest in Anglesey.
 Wales has the second highest rate of breast cancer incidence and
mortality among home countries in the UK.
 There are an average of 565 cases of breast cancer each year in North
Wales, with the highest average number in Flintshire, closely followed
by Conwy. The highest standardised incidence rates of breast cancer
are in Gwynedd and Conwy, which are significantly higher than the
Welsh average.
 There an average of 179 deaths from breast cancer in North Wales
every year. The highest average number were in Conwy and Gwynedd
and the highest mortality rate was in Conwy.
 The incidence of breast cancer has increased in all LHB areas in
North Wales over the last 10 years, although the gap between the
counties has narrowed in this period. Breast cancer in North Wales is
predicted to increase by between 15% and 36% by 2016-20 (subject to
caveats), a large potential increase in need.
 5-year relative survival from breast cancer in North Wales is lowest in
Gwynedd, Anglesey and Denbighshire and highest in Flintshire. In
general, North Wales patients have better survival that the Welsh
average.
 Hospital admission rates are a poor proxy for population health need.
The highest rate of hospital admissions for breast cancer in North
Wales was in Denbighshire, and lowest in Anglesey residents.
Admission rates in North Wales were about half those in Mid & West
Wales and less than one third those in South-East Wales. Rates of
bed use were highest in Gwynedd and lowest in Wrexham; rates in
North Wales were less than those in Mid & West Wales but greater
than those in South-East Wales. Average length of stay was highest
in Anglesey, lowest in Wrexham, and North Wales rates were higher
than that in Mid & West Wales and significantly higher than in SouthEast Wales. It should be noted that the significant differences in
admission rates, rates of bed use and average length of stay between
South-East Wales and the other two regions may lie in differences in
data collection (such as procedural coding) and require further
investigation.
 Overall Round 5 breast screening uptake in North Wales was lower
than the Welsh average. Within North Wales, the screening uptake
rate was lowest in Denbighshire and highest in Anglesey.
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4.0 Service profile
4.1 Patient Pathway
Figures 14 shows the current patient pathway from the N Wales Cancer Network
(Please note that screening MDTs are independent of symptomatic MDTs).
Figure 14: North Wales Breast Care Pathway
Screening
Genetics
GP
Referral
Symptomatic
Diagnostic
Clinic
Screening
Assessment
Clinic
MDT
Breast
Specialist
SNB
Oncologist
Reconstruction
Chemotherapy
Surgery
Radiotherapy
Hormone
Therapy
Plastic
Surgery
Reconstruction
Follow - Up
Lymphoedema
service
Palliative Care
Discharge
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4.2 Description of Services (37)
Information has been provided by use of the data contained in the Holcombe and
Raynor Report (1) for North West Wales NHS Trust including Llandudno Hospital,
and the Central Division of the North Wales NHS Trust (previously C&D Trust).
Further information has been provided by Mr Derrick Crawford and Mr Tibor Kovacs,
Consultant Surgeons specialising in breast cancer. Information for the Eastern
Division of the North Wales NHS Trust (previously NEWT) has been provided by the
General Manager Cancer Services; for the Countess of Chester by Ms Elizabeth
Redmond, Consultant Breast Surgeon; for Whiston by Alan Rushton-Woods, Senior
Information Analyst, and for BTW by Dr Rose Fox, Deputy Director of Screening
Services, Velindre NHS Trust. The Director of the North Wales Cancer Network has
validated this data, where possible.
4.2.1 North West Wales NHS Trust (NWWT)
The two major hospitals comprising North West Wales NHS Trust are Llandudno
Hospital (acute) and Ysbyty Gwynedd (major acute). In general, Llandudno Hospital
site serves substantial suburban populations of Llandudno, Colwyn Bay, Deganwy
and rural areas connected by A470 to the South. The Ysbyty Gwynedd site serves
substantial suburban populations of Bangor, Anglesey and Caernarfon and also rural
areas connected by A55 to the West and A487 to the South.
The breast care service is centred at Llandudno General Hospital, where the majority
of surgery is undertaken and new outpatients are seen. Some surgery and review
outpatient appointments take place at Ysbyty Gwynedd. The service is staffed by two
Consultant Surgeons with an interest in breast surgery, who provide the routine
breast service. The work performed in Llandudno is mainly implant based
reconstruction. This can be either immediate or delayed and is performed in
conjunction with a visiting plastic surgeon from Whiston Hospital. Complex
reconstructions are referred to Whiston Hospital Plastic Surgical Unit, which provides
a tertiary referral centre for breast plastic surgery.
In terms of facilities, Ysbyty Gwynedd has provision of on-site interventional
radiology (mammotome and MRI localisation). There is also on-site (ARSAC
licensed) nuclear medicine support for a full Sentinel Lymph Node (SLN) Biopsy
service with Lymphoscintogram, and on-site wire-guided surgical facilities. 24 hour
surgical and anaesthetics cover is also available at Ysbyty Gwynedd, as is HDU/ITU
and chemotherapy inpatient facilities. In contrast, Llandudno Hospital has relatively
poor diagnostic equipment, depends on BTW for use of Mammotome, has no breast
MRI available on-site (though has access to scanner at Ysbyty Gwynedd) and no
Lymphoscintogram facilities for SLN Biopsy (no nuclear medicine). Llandudno also
depends upon BTW for on-site localisation under imaging control, possesses no
HDU/ITU for complex breast cases/patients with concomitant medical problems and
has no surgical on-call cover (on-call is dependent on medical on-call support).
Both Llandudno Hospital and Ysbyty Gwynedd have good partnership working with
BTW. All radiologists see well in excess of the required numbers of mammograms.
Histopathologists support screening service and provide strong support to MDT and
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HER-2 and FISH testing (service offered regionally). The Trust also has a strong
recruitment record to Trials portfolio.
4.2.2 North Wales NHS Trust (Central Division) – formerly Conwy and
Denbighshire NHS Trust
The breast service is centred on the Ysbyty Glan Clwyd site, where most of the
surgery is undertaken and new and review outpatients are seen. Ysbyty Glan Clwyd
serves substantial suburban populations of Rhyl, Abergele, Prestatyn, Holywell and
rural areas to the South including Denbigh. The service is staffed by two Consultant
Surgeons with an interest in breast surgery, who perform the routine breast work.
There is an on-site reconstruction service which has been provided by two
Consultant Breast Surgeons for the last 18 months. Both immediate and delayed
reconstruction are provided, including implant based reconstruction, skin sparing
mastectomy and LD myocutaneous flap total or partial breast reconstruction, nipple
reconstruction and tattooing. All patients for free flap surgery, cosmetic breast
surgery congenital breast asymmetries and chest wall deformities are referred to
Whiston Hospital.
Radiology is not involved in the screening service and radiologists do not read >1000
symptomatic mammograms per year (2006 figures). In terms of facilities, there is onsite (ARSAC licensed) nuclear medicine support for a full SLN Biopsy Service with
Lymphoscintogram, on-site wire-guided surgical facilities, CT and MRI, and
ultrasound guided core biopsy. 24 hour surgical and anaesthetics cover is available
on-site at Glan Clwyd with an ITU and HDU. There is a strong recruitment record to
Trials portfolio in the Trust.
The North Wales Cancer Treatment Centre is also on site where all North Wales
patients receives their radiotherapy, as is a Department of Clinical Genetics which
received family history referrals for the North Wales Breast Service.
4.2.3 North Wales NHS Trust (Eastern Division) – formerly North East Wales
NHS Trust
This service is currently centred on the Wrexham Maelor hospital site, where all
surgery and outpatient activity takes place. The site serves a mixed population
reflecting past industrial heritage and rural areas to the south. The population is
largest around Wrexham itself and includes English residents registered to Welsh
GPs. The service is staffed by two Consultant Surgeons with an interest in breast
surgery, who perform the routine breast work. No immediate breast reconstruction
takes place at Wrexham with patients being referred for all types of reconstruction to
Chester.
In terms of facilities, there is provision of modern diagnostic facilities, equipment and
interventional radiology with an on-site (ARSAC licensed) nuclear medicine support
for full SLN Biopsy service and Lymphoscintogram. CT and MRI are also available,
as is ultrasound guided core biopsy. On-site wire-guided surgical facilities, 24 hour
surgical and anaesthetics cover is available on-site, as well as ITU and HDU.
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The service works along side the screening programme. HER2 and FISH are sent to
Christie Hospital. Visiting oncologists from the Cancer Centre are pivotal to support
an active MDT team working and core member of MDT. There is an on-site staff
grade haemato-oncologist support to consultant oncologist clinics and patients
attending the Chemotherapy Unit. There are increasing trials portfolio and
recruitment figures are within the targets set by the Clinical Trial Unit (CRC Cymru).
4.2.4 Countess of Chester (CoCH)
The service is centred at the Countess of Chester Hospital site, where surgery and
outpatient activity takes place. It serves a largely suburban population surrounding
the city. The Flintshire population in the east of the county access services at
Chester as a norm, leading to approximately 25% of patients in Chester being
registered with Welsh GPs. There are two female breast cancer surgeons at the
hospital, one of which has undergone further training in breast reconstruction work.
Chester also provides a tertiary/general plastics service accessed by Wrexham.
There is provision of modern diagnostic facilities, equipment and interventional
radiology, CT and MRI at the Unit. There is use of vacuum assisted biopsy
equipment for localisation and on-site wire-guided surgical facilities. There is also an
on-site (ARSAC licensed) nuclear medicine support for a full SLN Biopsy Service
and Lymphoscintogram (although this service, planned for 2009, is not yet
operational). 24 hour surgical and anaesthetics cover is available on-site, as well as
HDU and ITU. There is also on-site chemotherapy.
The Trust has good partnership working with a Screening Programme.
Histopathologists support screening service and provide strong support to MDT.
HER2 and FISH testing sent regionally but timely results are available. Visiting
oncologists from Cancer Centre helps to support active MDT team working. Lastly,
there is a strong recruitment record to Trials portfolio.
4.2.5 Breast Test Wales (38)
Background
Breast Test Wales (BTW) provides the NHS Breast Screening Programme in Wales.
It forms part of Screening Services, which is itself part of the Public Health Division
of Velindre NHS Trust. BTW adheres to the NHS Breast Screening Programme
(NHSBSP) guidelines, which include the standards and targets for performance and
outcome of the programme, for breast screening units and for technical and
individual professional performance.
All women resident in Wales aged
screening once every three years. In
to request screening. Women under
risk of breast cancer (as a result of
Author: Dr Rob Atenstaedt,
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between 50 and 70 are invited to attend for
addition, women aged over 70 are encouraged
the age of 50 assessed as being at increased
their family history, or previous treatment with
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mantle radiotherapy for Hodgkin’s disease) are also offered mammographic
surveillance. Currently around 100,000 women per year are screened for breast
cancer throughout Wales, around 20,000 in North Wales.
The number of women screened each year is increasing because of the increase in
the population in older age groups (approximately 2% per annum), reduction in
programme slippage, the invitation of women up to the age of 67 from 2003, and the
introduction of the service for women referred from the Genetics Service from 2001
onwards. From January 2006, the upper age for automatic invitation to screening
was raised to 70 years across Wales. Wales is considered to have an excellent
breast screening programme, which exceeds all the national cancer detection
standards.
Screening
BTW has four static centres – Cardiff (South), Swansea (West) and Llandudno
(North, with a satellite centre in Wrexham) supported by 10 mobile units (five in the
South, two in the West and three in the North). The screening itself is carried out
largely on the mobiles, by radiographers employed directly by BTW. A small number
of North Wales residents are screened by the Chester Breast Screening Programme.
Arrangements are currently being made to provide these women with screening
within Wales. Each static centre houses the programme’s administrative and nursing
staff, along with a screening promotion team. In addition, a number of multidisciplinary assessment teams are based in each static centre. Each team consists
of a specialist breast radiologist, a breast surgeon and a breast care nurse.
Surgeons and radiologists do not generally work exclusively for BTW, but also
provide the symptomatic service in Welsh NHS Trusts. In North Wales, assessment
teams are currently located at BTW’s centres in Llandudno (Bodnant) and the
Wrexham satellite centre. Three teams are based in Llandudno and one in
Wrexham.
Radiology
Mammograms taken on the mobile units are ferried by courier to either the
Llandudno (3/4) or Wrexham (1/4) centres for processing and film reading. Each
mammogram is examined by two specialist radiologists (Consultant or Associate
Specialist grade). Radiologists must meet BTW quality standards including reading
at least 5,000 films per year. Historically, recruitment to these specialist posts has
been difficult throughout the UK, and until the summer of 2008 the radiological
service in Wrexham was provided by a team based in Nottingham. BTW and North
Wales Trust have recently been successful in appointing a consultant radiologist to
work in Wrexham, and as of September 2008 all BTW work will be carried out by
specialists based in Wales. As stated above, Radiologists are also employed by local
Trusts for symptomatic work. There are 3 Breast Specialist Radiologists and one
Associate Specialist in BTW North Wales (Table 20).
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Table 20: Specialist Breast Radiology Staff N Wales, 2008
Initials Employing
Also works for
BTW
Trust
sessions/week
AG
NWWT
NWWT (Bangor)
5
KE
Velindre
NWWT (Bangor)
5
BB
Velindre
8
MP
Velindre
NWT (Wrexham)
5
Source: Breast Test Wales
Symptomatic
sessions/week
5
4
0
4
It can be seen from Table 20 that Velindre Trust (ie BTW) directly employs three of
the four specialist breast radiologists in North Wales. It can also be seen that
currently there is no BTW radiologist working in Ysbyty Glan Clwyd.
Film reading and consensus
Where the two radiologists reporting a woman’s screening mammogram agree that
the result is normal, the woman is informed by letter and her next screening
appointment date set for three years time. If both radiologists agree that the
mammograms show an abnormality, the woman is recalled to an assessment clinic
(see below). If one radiologist believes the film to be normal but the other feels an
abnormality is present, both review the film together to arrive at a consensus view.
This process means that it is essential for BTW radiologists to be physically present
in the BTW centre.
Assessment Clinics
Four BTW Assessment Clinics are held per week in North Wales, three in Llandudno
and one in Wrexham. Work is ongoing towards sharing the premises in Wrexham as
a combined centre, although this will not be able to occur until BTW have digital
technology in place, which is estimated may take up to two years.
Approximately 1 in 20 women screened are called back for assessment per year,
around one in six of whom will receive a breast cancer diagnosis. This means that in
North Wales around 1,250 women are recalled for assessment each year and of
those, approximately 200 will have cancer. At the assessment clinic the woman is
seen by the multidisciplinary team and will have a clinical examination, further
specialised mammographic views or ultrasound and biopsy of abnormal areas as
appropriate.
As with radiology staff, the breast surgeons working for BTW also have commitments
in the symptomatic services (Table 21)
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Table 21: BTW Breast Surgeons - North Wales, 2008
Initials
Employing Trust Also works for
BTW
sessions/week
DC
NWWT
NWWT (Bangor 2
& Llandudno)
ML
NWWT
NWWT (Bangor 2
& Llandudno)
TK
NWT
NWT
(Glan 2
Clwyd)
RC
NWT
NWT (Wrexham) 1.5
TG
NWT
NWT (Wrexham) 1.5
Source: Breast Test Wales
Symptomatic
sessions/week
8
8
8
8.5
8.5
Biopsy samples taken in BTW assessment clinics are reported by pathologists in
Bangor (for women seen in Llandudno) or Wrexham (for women seen in Wrexham).
Results are reviewed and treatment plans formulated at a weekly MDT meeting held
in Llandudno. The necessity to ‘buy in’ radiology services from Nottingham for
Wrexham women has meant that it has not been possible to hold a formal MDT in
Wrexham to date. With the recent appointment of a breast radiologist, a weekly MDT
will be held in Wrexham from September 2008 onwards.
Surgery
If women do not have cancer, they are discharged. If they have a cancer diagnosis
they will be given a date for surgery. Theoretically, this is where screening services
responsibility ends. Breast cancer patients will be reviewed according to the
protocols of the treating Trust. If they are seen by a consultant in NWWT, they
usually have their surgery done in Llandudno.
Although BTW’s remit extends only to the point of diagnosis of breast cancer, in
practice the concentration of specialist radiological skills in BTW has resulted in the
informal provision of a service to Trusts for the insertion of guidewires prior to
surgery. Women who are referred for surgery (from screening or symptomatic
services) often have small, impalpable tumours. In order for the surgeon to be sure
that the correct tissue is being removed at operation, a localisation guidewire is
inserted in the breast by a radiologist under X-ray or ultrasound control. Women
having surgery in Llandudno or Wrexham are frequently referred to BTW for
guidewire insertion. This process is aided by the close proximity of the BTW centres
to the treating unit. BTW performs 2-3 of these procedures per week in Llandudno
and a similar number in Wrexham.
Performance of Breast Test Wales
The overall statistic that best encapsulates the performance of a breast screening
programme is its Standardised Detection Ratio (SDR) i.e. the number of cancers
diagnosed compared with the number that would be expected to be diagnosed if
BTW was performing as well as the RCTs on which the programme is based (age
standardised). An SDR of >1 means you’re doing better than the Scandanavian
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programmes that provided the evidence base for breast screening. BTW’s SDR for
2006/7 was 1.63 (Prevalent), 1.34 (Incident) and 1.40 (overall), which are some of
the best results in the UK.
4.2.6 Volumes and Activity
Tables 22-29 in Appendix 5 provides information presented as volumes of activity
and bed use using 2006 data (calendar year) and includes figures that relate to
multidisciplinary meetings, referral, diagnosis, follow up appointments, waits, and
screening round length. Tables on staffing complement and vacancies are also given
detailing figures for both core and extended team members. This is followed by
tabular descriptions on the following: Treatment; Pathology; Imaging; Reading, and
SLN Biopsy. Information has been provided by the sources outlined at the beginning
of the section. Cancer surgery is not included in those procedures included in
Access 2009 and as such is not subject to this waiting time measure. Cancer waiting
times for first definitive treatment do apply to breast cancer services and all breast
cancer MDTs serving the North Wales population are compliant with these targets. It
can be seen that in 2006:







NWWT had the highest number of referrals for North Wales residents followed
by Wrexham Maelor and YGC. It also diagnosed the greatest number of
breast cancers among Trusts.
Whiston performed the majority of reconstructions for North Wales patients.
In terms of case volumes, all Trusts saw more than 100 new breast cancers
per year and most see more than 150.
All Trusts hold weekly MDT meetings.
MDT membership is compliant and attendance is good for all Units.
All Trusts have the full range of extended team members, though virtually
none of these attend MDT meetings.
According to the North Wales Cancer Network, all the breast cancer teams
are compliant with the cancer waiting times.
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Key Messages:








The current breast care service to North Wales residents is provided
by NWWT via Ysbyty Gwynedd and Llandudno Hospital sites, NWT
through Ysbyty Glan Clwyd And Wrexham Maelor Hospitals and the
CoCH. Whiston performs the majority of reconstructions for North
Wales patients.
Breast screening is provided by BTW, a national screening service.
BTW provides a high quality breast screening service with a high
Standardised Detection Ratio for breast cancer from its two static
centres in Llandudno Hospital and Wrexham, as well as three mobile
units.
In the period studied, NWWT had the highest number of referrals for
North Wales residents followed by Wrexham Maelor and YGC. NWWT
also diagnoses the greatest number of breast cancers among Trusts.
In terms of case volumes, all Trusts see more than 100 new breast
cancers per year and most see more than 150.
All Trusts hold weekly MDT meetings.
MDT membership is compliant and attendance is good for all Units.
All Trusts have the full range of extended team members, though
virtually none of these attend MDT meetings.
All the breast cancer teams are compliant with the cancer waiting
times.
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5.0 Service model/option appraisal
5.1 Literature Review
5.1.1 Search strategies
Scope
A systematic literature search was carried out by Library & Knowledge Management
Services (LKMS) of the NPHS, to identify evidence of best practice in the delivery of
breast services. Search strategies are available in Appendix 6.
Search methodology
The following electronic databases and websites were searched from 1996-August
2008.
Electronic databases

Medline

Cochrane library

Embase

Map of Medicine


HMIC

British Nursing
Index
CINAHL
Websites

NICE

ASCO – American
Society of Clinical
Oncology

EUSOMA –
European Society
of Breast Cancer
Specialists

BAPRAS – British
Association of
Plastic
Reconstructive &
Aesthetic Surgeons

NLH specialist
libraries – Cancer,
Women’s Health

Royal College of
Surgeons

BASO – British
Association of
Surgical Oncologist

NHS Cancer
Screening

Royal College of
Nursing

Clinical Evidence
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The government department health websites of England, Scotland, Northern Ireland
and the Irish Republic were also searched for comparative service reviews.
Specialist cancer research websites were trawled for recent reports and work in
progress.
Search filters were developed by LKMS consisting of both subject headings and
free-text keywords. A general filter was developed to capture breast services. This
was not a single structured search strategy but a series of topic based searches on
various components of the service provision such as needs assessment,
epidemiology, quality standards, comparative service models, such as day surgery
provision as well as specific treatments and diagnostics. This approach increased
the sensitivity of the search in order to provide a comprehensive and focussed view
of the available evidence. Questions looked at in the literature review included:






What is the epidemiology of breast disease (breast cancer and benign breast
conditions) ? [1996-]
What are the elements of a high quality breast care services? [1996-]
What breast care models are currently in operation in the UK/ Europe/
Developed World? [1996-]
To locate general review papers on aetiology, prevention and management of
breast diseases [1994-]
Is there any evidence that surgery for breast cancer can be done as a day
case procedure? [1996-]
Is there any guidance on how the following services should be organised:
[1996-]
- Oncoplastic breast surgery
- Localisation biopsy/guide wire breast excision
Inclusion criteria
Benign breast diseases and breast cancer
Study designs -No filters were applied to limit to specific research designs, such as
RCTs, meta analysis.
English language
Exclusion criteria
Studies and papers relating to services in developing world have been excluded,
which have limited generalisability to the North Wales setting.
Selection of studies
The database searches identified 211 possibly eligible references. The titles and
abstracts of search results were screened for relevance by the author. 160 were
judged to be relevant and for a number of these a full article was obtained by LKMS.
Other papers were found by the authors from the gray literature.
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Best Practice Guidance in Breast Care Services
The NHS breast screening programme was first introduced in 1987. The first widely
disseminated guidelines on the management of breast cancer in the UK appeared in
1992 (39). Guidance on the management of symptomatic breast disease followed in
1995 (40). In the same year, a national Expert Advisory Group was set up to make
recommendations on the organisation of cancer care in England and Wales. Their
report set out a model of care for symptomatic patients based on three levels of
service provision (41):



Primary care - involved in the initial assessment and referral of patients and in the
provision of ongoing practical and emotional support to patients.
Designated cancer units - responsible for the clinical management of a common
cancer, such as breast cancer and would have a lead consultant responsible for
coordinating care, a range of site-specific specialists and input from non-surgical
oncologists.
Cancer Centres – responsible for the provision of specialist services to support
cancer units. Serving a population of between 600,000 to one million, they would
provide radiotherapy services, specialist diagnostic services, management of rare
cancers and intensive chemotherapy regimes.
Cancer Units would provide an equivalent level of service to a Cancer Centre,
although it was likely that some facilities such as radiotherapy might not be available
locally in cancer units.
In 1996, the Department of Health produced ‘Improving Outcomes in Breast Cancer’,
(42) which detailed which healthcare professionals should be involved in the
management of women with breast cancer and also described how these services
should be organised so that all women with breast cancer across England and
Wales would receive optimum healthcare.
The first European Breast Cancer Conference took place in 1998. Delegates
released the 'The Florence Statement' (43) which expressed the view that all women
in Europe should have access to multidisciplinary breast clinics based on
populations of around 250,000; it also called for mandatory quality assurance
programmes for breast services across Europe. The establishment of a working
party led to the publication of 'Requirements of a Specialist Breast Unit' in 2000 (44).
These guidelines have been influential in the introduction of the multidisciplinary
working in several countries. 'The Brussels Statement' (45) drew attention to these
guidelines and demanded that processes of accreditation of breast units be
implemented. The importance of the establishment of multidisciplinary breast units
was again stressed in 'The Hamburg Statement' (46), approved in 2004 by the
European Parliament.
2000 saw the introduction of the NHS Cancer Plan, which promised improved
access and waiting times for people already diagnosed with or thought to have
cancer (47).
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In 2002, the National Institute of Clinical Excellence (NICE) produced updated
guidelines on improving the outcomes for patients with breast cancer (48). The key
recommendations were that women should be treated by a multidisciplinary team,
women should be treated promptly, services should be more consistent and that
intensive, hospital-based follow-up for breast cancer patients is not beneficial.
The National Breast Cancer Standards, issued in 2005, define the core aspects of
the service that should be provided for cancer patients throughout Wales (49). These
standards built on those published in 2000 and take account of the NICE cancer
service guidance.
The Scottish Intercollegiate Guideline Network (SIGN) produced evidence-based
guidance on the management of breast cancer in the same year (50). Among a
number of recommendations, it stated that patients should be seen at one-stop,
multidisciplinary clinics involving breast clinicians, radiologists and cytology. Breast
care nurses with appropriate training should be part of the clinical team and
psychological support should be available to women diagnosed with breast cancer at
the clinic.
Also published in 2005, the BASO Guidelines for the management of symptomatic
breast disease recommended that breast cancer care should be provided by breast
specialists in each discipline (51). These specialists should work as a team and
provide a spectrum of services, ranging from early detection of breast cancer
through to the care of patients with advanced disease.
In 2006, the Welsh Assembly Government produced ‘Designed to Tackle Cancer in
Wales’ (52). This set out the Assembly Government’s policy aims and strategic
direction to tackle cancer. The policy aims included themes such as more
prevention, early detection, improved access and better services for cancer. It also
contained a number of implementation targets for the period up to March 2008. The
targets are mainly for cancer in general, although there is one stating that BTW
should continue to improve its detection rate. A second strategic framework,
covering the period 2008 to 2011 has just been released (53). One of the new
targets within this is to implement the NICE guidance for patients with a familial risk
of developing breast cancer, taking account of Cancer Services Coordination Group
(CSCG) advice (54).
The fourth edition of the European guidelines for quality assurance in breast cancer
screening and diagnosis was published in 2008 (55). The guidelines set out a
number of recommendations designed to improve the quality of breast screening,
diagnosis and treatment of breast cancer, and to reduce the differences among EU
countries in the quality of care of breast disease.
In August 2008, NICE published draft guidelines for consultation on early/locally
advanced breast cancer (56) and on advanced breast cancer (57).
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5.3 The Breast Care Patient Journey (20)
There are six main sub-categories of women accessing breast care services:






Women attending screening services
Women with a family history of breast cancer
Women presenting for assessment of symptoms suggestive of breast cancer
Women requiring treatment for benign breast conditions
Women requiring treatment for breast cancer
Women requiring treatment for psychological morbidity
5.3.1 Women attending screening services
Clinical and Cost Effectiveness
Evidence is that breast self-examination is not effective as a population based
screening test (58). NICE (48) confirms that that there is no reliable evidence of any
benefit associated with breast examination in any group of women. However, RCTs
suggests that population based mammographic screening can reduce mortality from
breast cancer by up to 30% in women aged 50 to 69 (59,60).
The Forrest Report (61) calculated the cost-effectiveness of a breast screening
programme using information from the Swedish two counties and Health Insurance
Plan (HIP) trials, assuming a 70% uptake of screening, a three-year screening
interval and the use of single-view mammography. The estimate of 3500 per life-year
saved (1983/84 prices) compared favourably with the cost-effectiveness of other
health service interventions, such as coronary artery bypass grafts.
The cost-effectiveness of a population based screening programme is influenced by
the following factors (20):


Age group invited for screening – women aged between 50-70 are
routinely invited for screening in Wales. There is insufficient evidence to
support mammographic screening in the general population under the age of
50, although a recent study has suggested that screening in the UK should
begin at age 47 (62). There is insufficient evidence of efficacy of screening
over 70 as most trials have an upper age limit of 69. However, women over 70
can self present for screening in Wales.
Screening interval period - BTW and the NHS Breast Screening Programme
is unique among population based screening programmes in that the interval
between screens is three years. The first population-based report describing
the incidence of interval cancers in the NHS Breast Screening Programme
found that the rate of interval cancers in the third year after screening
approached that which would be expected in the absence of screening (63).
This suggested that the screening interval might be too long. However, a large
RCT involving 76,000 women to consider the optimum screening interval
compared annual mammography with 3-yearly mammography over a period
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of 7 years, concluded that shortening the screening interval from three years
did not produce a statistically significant decrease in the predicted mortality
from breast cancer (64).
Sensitivity of the tests - Although not all cancers are detectable by
mammographic screening, improvement in the sensitivity of this test will
identify some cancers which would otherwise have been missed. One way in
which the sensitivity of the screening test can be further improved is by
optimising the optical density of the mammographic film (65) and by 2
radiologists independently reading the mammogram (double reading) (66) and
by employing two view mammography (67). Originally the NHS breast
screening programme involved one view of each breast at every appointment.
Two view mammography was introduced following an RCT that showed a
24% increase in cancer detection rates as a result of two view mammography
at the first appointment (68). Recent epidemiological evidence has shown an
increase of 45% in detection of small invasive cancers when double view
mammography is used at prevalent screens, and a 42% increase at incident
(subsequent) screens (69). BTW has used two view mammography at the
initial screen since its inception and two view mammography at subsequent
screens since 2001. The fourth edition of the European guidelines for quality
assurance in breast cancer screening and diagnosis (55) mentions that fullfield digital mammography can achieve high image quality and is likely to
become established due to multiple advantages such as image manipulation
and transmission, data display and future technological developments. Digital
mammography has replaced conventional mammography in some breast
screening centres in the UK. While it may not have major clinical advantages
over film screen mammography, it does detect additional cancers (70)
although this might be counterbalanced by a higher recall rate (71). All
mammography currently carried out by BTW uses film based (analogue)
technology. Most NHS Trusts use digital equipment, and as BTW replaces its
equipment over the next several years it is proposed to install digital
technology, both in the mobile units and the static centres.
Compliance – the effectiveness of population based breast screening
programmes will be adversely affected by low compliance (72). A number of
factors can affect compliance, including:
-
-
Accuracy of population registers (72).
Accessibility of primary screening facilities. The location of primary
screening facilities can affect uptake (73). A Scottish study (74) found
that access costs were directly associated with screening uptake.
Mobile units, such as those used by BTW, reduce access issues.
Acceptability of screening. There is no real evidence that the screening
programme increases psychological morbidity among women invited
for screening. (75,76). More than 90% of screened women will reattend for further screening; women who do not are more likely to view
the previous experience of screening negatively (77). However, the
majority of women with screen-detected abnormalities will eventually
have a benign diagnosis (false positives). These healthy women will
undergo unnecessary investigation and sometimes treatment with the
possibility of resultant physical and psychological morbidity (78).
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Method of invitation. Studies have shown the efficacy of personalised
letters of invitation in improving compliance (79). Williams and Vessey
demonstrated the superiority of pre-allocated appointments (80), for
example.
Organisation of Screening Service
EUSOMA (44) recommends that population breast screening programmes should be
based within or be closely associated with a recognised Breast Unit and not working
as a separate service. The radiologists, surgeons and pathologists working in the
screening programme must be core members of the associated Breast Unit. NICE
(48) specifically recommends: ‘Breast Test Wales should continue to seek
opportunities for collaboration between the screening and symptomatic services with
the cancer network’.
5.3.2 Women with a family history of breast cancer
A family history of breast cancer is given by 20% of all women with the condition.
Women with a first degree relative with breast cancer have up to a three fold
increased risk of developing the disease. If two or more relatives are affected, then
the relative risk of breast cancer can be more than 10 fold that of the general
population (81). There has been a considerable amount of research aimed at
identifying the genes responsible for breast cancer. The BRCA1 and BRAC2 genes
are likely to cause the majority of genetically determined cases.
According to NICE (48), women seeking advice with regard to risk e.g. family history,
must be able to receive advice from the Breast Team, which must also include a
clinical geneticist with a special interest in breast cancer. Furthermore, NICE have
recently produced specific guidelines on the classification and care of women at risk
of familial breast cancer in primary, secondary and tertiary care (54). This states that
all women aged 40-49 years satisfying referral criteria to secondary or specialist care
(at raised risk or greater) should be offered annual mammographic surveillance. In
addition, women who are known to have a genetic mutation should be offered annual
MRI surveillance if they are: BRCA1 and BRCA2 mutation carriers aged 30-49 years;
TP53 mutation carriers aged 20 years or older. MRI surveillance should be offered
annually where indicated: From 30-39 years: to women at a 10-year risk of greater
than 8% From 40-49 years: to women at a 10-year risk of greater than 20%, or to
women at a 10-year risk of greater than 12% where mammography has shown a
dense breast pattern. NICE has added that genetic testing is only appropriate for a
small proportion of women who are from high risk families. Lastly, risk reducing
surgery (mastectomy and/or oophorectomy) is appropriate only for a small proportion
of women who are from high risk families and should be managed by an MDT. One
of the targets of ‘Designed to Tackle Cancer in Wales - Strategic Framework’ (53) is
that this NICE guidance be implemented in Wales.
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5.3.3 Women presenting for assessment of symptoms suggestive of breast
cancer
About one third of all women with a breast related problem will have a painless
breast lump, of whom one in eight will have breast cancer (82,83). Other symptoms
may include skin dimpling, bloody discharge from or retraction of the nipple.
Consensus supports a triple assessment approach in the assessment of
symptomatic women (84,85). This involves clinical examination, breast imaging
(mammography and/or ultrasound) and either cytological (FNAC) or histological (trucut biopsy) assessment. The aim of triple assessment is to improve cancer detection
rates while limiting the number of unnecessary surgical interventions. NICE (48)
states that triple assessment should be available for women with suspected breast
cancer at a single visit. BASO guidelines (86) agree that diagnosis should be based
on triple assessment, where an initial clinical assessment may be followed by
appropriate imaging, fine needle aspiration and/or core needle biopsy. They add that
not every patient will require each aspect of triple assessment.
Biopsy Techniques
The different methods of performing a biopsy are outlined below (87):




Fine Needle Aspiration (FNA) – removal of cells from the breast using a 21-g to
25-g needle inserted into the lesion.
Core Needle Biopsy (CNB) – similar to FNA, but the physician uses a large core
needle with a special cutting edge and a spring-loaded device to remove multiple
core samples of breast tissue. Ultrasound or stereotactic guidance can be used.
Internationally, CNB has widely replaced cytology obtained by fine needle
aspiration biopsy (FNA) and is the established method of sampling image
detected lesions (88).
Vacuum-assisted breast biopsy – similar to CNB, but has the added advantage
of combining suction and needle rotation to eliminate the need for retargeting the
lesion. This yield larger cores of tissue and provides the pathologist with more
specimen for diagnosis.
Excision biopsy with wire localization – this is the surgical removal of a
nonpalpable breast lesion after a radiologist places a wire in the breast. Using
ultrasound or radiographs with or without stereotactic methods, a hooked wire is
placed close to a mammographic abnormality under local anaesthesia.
Mammograms confirm the position of the wire in relation to the abnormality.
Under general anaesthesia, an incision is made that incorporates the wire, which
is then followed to remove the piece of tissue. A radiograph is then taken to
confirm removal of the abnormality. Surgical excision following needle-wire
localisation of non-palpable, mammographically detected breast lesions is a very
valuable diagnostic and therapeutic procedure. According to the Quality
Assurance Guidelines for Surgeons in Breast Cancer Screening, (90) needle
biopsy of screen detected lesions should be performed on no more than two
occasions. If the diagnosis is till not established, the surgical biopsy should be
performed. As we have seen, women having surgery in Llandudno or Wrexham
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are frequently referred to BTW for guidewire insertion, more frequently for
treatment rather than diagnostic purposes.
Magnetic Resonance Imaging (MRI)
Interest in breast MRI in recent years has largely been focused on its role in
screening women with inherited mutations of the breast cancer genes (BRCAI or
BRCA2), who make up between 5-10% of women with breast cancer. (88)
Mammography has a very poor sensitivity for cancer detection in women with gene
mutations, detecting fewer than 50% of the cancers that develop in this group. A
recent UK trial has shown that MRI has a much higher sensitivity than
mammography (77% vs 40%, P=0.01), but with significantly lower specificity. As we
have seen, NICE (54) has recommended that women at increased risk of breast
cancer as a result of their family history be offered annual MRI scanning.
The fourth edition of the European guidelines for quality assurance in breast cancer
notes that MRI is not yet part of initial workup or routine follow-up for breast cancer
(55). Its role is under evaluation, although it has an established place in the
investigation of implant dysfunction, recurrent or multifocal malignancy. It further
mentions that its place in screening of women belonging to high risk groups is being
investigated. It recommends that it is best carried out in units with a large throughput,
having expertise and equipment to proceed to MRI guided biopsy if necessary. Draft
NICE guidance on early and locally advanced breast has recommended that MRI
should be offered to patients with invasive breast cancer in the following instances
(56):



if there is discrepancy between the clinical and radiological assessment of
disease extent
if breast density precludes accurate mammographic assessment
to assess tumour size if breast conserving surgery is being considered for
invasive lobular cancer.
5.3.4 Women requiring treatment for benign breast conditions (19)
There are a number of different treatments for breast pain. These include using
warm baths, heating pads, or ice packs to help to ease the pain or being prescribed
one of a variety of medications available including danazol, gestinane or tamoxifen.
If an individual is diagnosed with a benign breast lump, it can often be left. However,
some women choose to have a lump, such as a fibroadenoma surgically removed,
particularly if it is large.
For breast cysts, a small needle and syringe (aspiration) is sometimes used to draw
off the fluid. After the cyst has been drained, the lump usually disappears. The fluid
is sent for pathological examination. Although most cysts are benign, they are
occasionally linked to an increased risk of developing breast cancer. Approximately
30% of cysts refill with fluid and need to be drained again.
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EUSOMA state that the Breast Unit must advise and where necessary treat women
with benign breast disease (44).
5.3.5 Women requiring treatment for breast cancer
The appropriate management of women with early breast cancer offers opportunities
to reduce morbidity and mortality. The objectives of clinical management vary with
the extent of the disease as shown in Table 30 (20):
Table 30: Objectives of Clinical Management
Subgroup
Objectives
DCIS
Local control of disease
Early Breast Cancer
Loco-regional control. Prolongation of
disease-free and overall survival
Locally advanced breast cancer
Local disease control. In some women,
prolongation of overall survival
Metastatic breast cancer
Palliation
Ductal carcinoma in situ
Surgical management, mastectomy (removal of the breast) or breast conservation
therapy (BCT) aims to achieve local control (92). Mastectomy will cure 98-100% of
women with symptomatic ductal carcinoma in situ (92). However, as screen detected
asymptomatic DCIS is usually small and localised, there has been a marked shift
towards the use of BCT to treat these lesions. Recurrences are common. In one
series, one quarter of women had recurrences at 10 years of which half were
invasive (93). Draft NICE guidance (56) on early and locally advanced breast cancer
has recommended that all patients having breast conserving surgery for ductal
carcinoma in situ (DCIS) should have clear margins of excision of a minimum of 2
mm, with pathological examination to NHSBSP reporting standards. If the margin is
less than 2 mm, re-excision should be carried out.
Early breast cancer
Clinical management of women with early breast cancer aims to achieve locoregional control of disease and prolongation of disease-free and overall survival (94).
The clinical management of early breast cancer has four main components:

Primary treatment of the breast and axillary lymph nodes to gain locoregional control of disease - Two equally efficacious treatments are
available for patients with Stage I or II breast cancer – either modified radical
mastectomy (MRM) or BCT, followed by radiotherapy (95). BCT surgery
ranges from a lumpectomy, or wide local excision, in which just the tumour
and a little surrounding breast tissue is excised, to a partial mastectomy or
quadrantectomy, in which up to a quarter of the whole breast is removed.
Recently, Marrazzo et al (96) have reported that quadrantectomy and
associated sentinel lymph node biopsy is the gold standard treatment of early
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breast cancer. Treatment of the axilla, either by surgery or by radiotherapy is
effective in maintaining local control of disease (97). Side effects include
lymphodoema, limited shoulder movement and inadvertent damage to the
brachial plexus.
Pathological staging to direct decisions on adjuvant therapy Pathological assessment of the tumour and lymph nodes identifies women
who would benefit from adjuvant therapy such as chemotherapy, tamoxifen
and ovarian oblation. Both the tumour and lymph nodes need to be assessed.
For the tumour, the histological type, grade and size provide important
prognostic information. In the assessment of axillary lymph nodes, clinical
examination is unreliable and surgical excision of axillary lymph nodes for
pathological examination is essential as axillary lymph node status is the most
significant individual prognostic factor in patients with breast cancer (98).
Surgical dissection or clearance, undertaken as part of the primary surgical
treatment, usually provides sufficient lymph nodes to stage the axilla, but this
procedure is associated with significant morbidity and provides no benefit for
most women with breast cancer who do not have axillary node involvement
(88). Sentinel lymph node (SLN) Biopsy has therefore emerged as an
accurate, minimally invasive procedure to assess axillary node status in
patients without evidence of nodal disease on clinical or ultrasound
assessment. A SLN is any node/ nodes receiving lymphatic drainage from a
primary tumour site and the procedure relies on the assumption that if the
SLN is clear of metastases, the remainder of nodes in the axilla are too. The
gold standard localisation of SLN in the breast is achieved by injecting blue
dye and radioactive colloid tracer into the breast with a preoperative
Lymphoscintogram to determine whether or not there has been any uptake of
radioisotope by the breast lymphatics and establish whether or not this has
gone to the axilla (99). Localisation rates of over 95% are possible, with the
highest rate of node detection (>99%) coming from injection in the subareolar
region. Rates of false positives can be as low as 5%. SLN Biopsy causes
significantly less morbidity than axillary dissection and recovery is quicker
(88). Randomised studies have shown that SLN biopsy is a safe and effective
alternative to axillary node dissection for nodal staging in patients with
clinically node-negative early breast cancer (102,103) and is associated with
reduced arm morbidity and better quality of life than axillary dissection (103).
Demand on resources is less, and there are reductions in operation time,
drain use and hospital stay (102). However, it is not yet known whether SLN
Biopsy improves long-term survival compared with axillary clearance (104).
SLN biopsy is fast becoming established as an accurate method of staging
axillary lymph node involvement in breast cancer (104). The American Society
of Clinical Oncology (ASCO) recently convened an expert panel to conduct a
systematic review of the literature available on the use of SLN Biopsy in early
stage breast and supported the use of SLN Biopsy for staging disease in most
women with clinically negative axillary lymph nodes. The Group noted that
SLN Biopsy is a reliable technique in trained hands and has an acceptable
false-negative rate in both mastectomy and breast conserving surgery.
However, they concluded that axillary node dissection (ALND) should be
performed when the SLN Biopsy procedure fails or is technically
unsatisfactory or when clinically suspicious nodes are present in the axilla
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after all sentinel lymph nodes have been removed. The Panel also
recommended that suspicious palpable nodes should be submitted as SLNs,
and that the surgeon should have a low threshold for default to ALND in this
context. A summary of their recommendations is given in Table 31:
Table 31: ASCO Guideline Recommendations for SLNB in Early-Stage Breast
Cancer

Draft NICE guidance (56) on early and locally advanced breast cancer has
recommended that all patients undergoing primary surgical treatment for
invasive breast cancer should be offered axillary staging by minimal surgery
rather than node clearance, if pre-operative evaluation of the axilla shows no
evidence of metastases; SLN Biopsy is the preferred option. SLN Biopsy is
offered by all NHS Trusts serving North Wales residents except for Llandudno
Hospital and the Countess of Chester currently (although the latter is planning
to introduce in 2009).
Adjuvant therapy to prolong disease-free and overall survival –
Radiotherapy should be offered to all women after BCT, but is not necessary
after mastectomy. Radiotherapy after BCT improves disease free survival. A
meta-analysis of worldwide trials investigating hormonal, cytotoxic and
immune therapy in early breast cancer has produced evidence of the
effectiveness of these treatments in improving overall survival (107). If the
breast cancer is found to be hormone receptor positive at the time of
diagnosis, it may be possible to treat the individual with hormone therapy to
minimise the risk of the cancer recurring. Tamoxifen is the most common type
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of hormone therapy. They also include aromatase inhibitors and pituitary
downregulators. If the cancer is found to be HER2 positive at the time of
diagnosis, it may be possible to treat with biological therapy such as
herceptin. Draft NICE guidance (56) on early and locally advanced breast
cancer has recommended that adjuvant chemotherapy or radiotherapy should
be started as soon as possible and within six weeks of completion of surgery,
in patients with early breast cancer who require it. It also states that postmenopausal patients with ER positive early breast cancer not considered low
risk should be given an aromatase inhibitor (AI) as their initial adjuvant
therapy. In addition, it recommends that patients with early invasive breast
cancer should receive a baseline dual energy X-ray absorptiometry (DXA)
assessment of bone mineral density (BMD) if they:
- are starting adjuvant AIs
- have treatment-induced menopause
- are commencing ovarian suppression therapy.


The UK NHS Cancer Services Collaborative/Improvement Partnership (108)
recommends that delays to adjuvant therapy can be minimised by prebooking appointments for chemotherapy and radiotherapy as part of the MDT
meeting via the MDT coordinator.
Routine follow-up - Women with early breast cancer may develop local
recurrences (9% after 10 years) or distant metatases and have a four-fold
increased risk of developing cancer in the contralateral breast (109,110). A
Cochrane Review looked at follow-up of breast cancer patients and found that
a regular physical and yearly mammogram are as effectives as more intense
methods of examination such as liver scans, tumour markers, chest X-rays
and blood and liver function tests in detecting recurrent breast cancer. Draft
NICE guidance (56) on early and locally advanced breast cancer has
recommended that the NHS offers annual mammography until a minimum
age of 70 years and to the standard of the NHSBSP to patients treated for
early breast cancer, including ductal carcinoma in situ (DCIS).
Reconstructive/Oncoplastic Breast Surgery - Women undergoing
mastectomy may need reconstructive surgery or breast prostheses. This may
be done either by inserting a breast implant, or by using tissue from another
part of the body to create a new breast. There are effectively three types of
reconstruction procedure:
-
Implant Based Reconstruction
Pedicled Mycocutaneous Flap Reconstruction
Free Myocutaneous Flap Reconstruction
Recent advances include the increasing use of skin sparing mastectomy
(which removes the breast tissue but preserves most of the breast skin)
combined with immediate breast reconstruction using a latissimus doris (LD)
flap or a transverse rectus abdominus mycocutaneous (TRAM) flap (112).
Other improvements include extending the dissection to include fat over the
LD muscle so that an implant is not required, and raising the lower abdominal
fat and skin on the deep inferior epigastric vessels (the so-called diep flap)
alone, thereby sparing the rectus muscle.
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Breast reconstruction is a safe procedure and has no impact on detection of
recurrence or overall survival (113). Reconstructive surgery may be
undertaken at the same time as the primary surgery or as a delayed
procedure (114,115). Evidence indicates that immediate breast reconstruction
does not adversely affect breast cancer outcome (116,117). In addition, it has
been argued that immediate reconstruction has economic benefits, produces
better results than delayed reconstruction and reduces the psychological
morbidity associated with mastectomy (118). According to EUSOMA (44), a
breast unit must provide breast surgical reconstruction when required for
those patients not suitable for breast conserving therapy and be able to apply
special techniques for patients with extensive local disease. The breast
surgeons in the team should be able to undertake basic reconstruction or
reconturing and there should be a standard arrangement or joint
reconstruction clinic with one or two nominated plastic surgeons (non-core
team member) who take a special interest in breast reconstructive and
reconturing techniques. NICE (48) recommends that breast reconstruction
should be available at the initial surgical operation. 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. Recent British guidelines (119) on oncoplastic breast surgery
state that the oncoplastic service should normally be on site and will constitute
a core component of the multidisciplinary team.
Locally –advanced breast cancer
Treatment for locally advanced disease aims to control local disease and includes
surgery, radiotherapy and systematic therapy (120,121). In some women, treatment
also aims to prolong overall survival.
Metastatic Breast Cancer
The management of women with disseminated breast cancer is palliative and aims
to ameliorate and control distressing symptoms. Treatments include systematic
therapy (chemotherapy or hormone therapy) and radiotherapy. The first line drug of
choice is tamoxifen. Other hormone therapies and ovarian ablation are used
sequentially as breakthrough of disease occurs. Chemotherapy is usually offered
when hormones fail. Trials do not demonstrate any benefit of multi-agency
chemotherapy over a single agent (124). Palliative radiotherapy is useful for the
treatment of bone, brain and skin metastases. NICE (48) recommends that a
specialist palliative care service must be available for the referral of patients with
advanced breast cancer. Draft NICE guidelines (57) for advanced breast cancer are
currently out for consultation and make the following recommendations:
Presentation and diagnosis:
 PET-CT should only be used to make a new diagnosis of metastases for
patients with breast cancer whose imaging is suspicious but not diagnostic of
metastatic disease.
 If receptor status (oestrogen receptor and HER2) was not assessed at the
time of initial diagnosis, then it should be assessed at the time of tumour
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recurrence. In the absence of any tumour tissue from the primary tumour a
biopsy of a metastasis should be obtained if feasible.
Systemic disease-modifying therapy
 For patients with hormone receptor-positive advanced breast cancer, offer
endocrine therapy as first-line treatment unless there is a clinical need to
achieve a rapid tumour response.
 For patients with advanced breast cancer who are not suitable for
anthracyclines (adjuvant anthracyclines or first-line metastatic anthracyclines,
or contraindicated), systemic chemotherapy should be offered in the following
sequence:
- first line: single-agent docetaxel
- second line: single-agent vinorelbine or capecitabine
- third line: single-agent capecitabine or vinorelbine (whichever was not
used as second-line treatment).
 Patients who are receiving treatment with trastuzumab should not continue
trastuzumab at the time of disease progression outside the central nervous
system.
Community-based treatment and supportive care
 Healthcare professionals involved in the care of patients with advanced breast
cancer should ensure that the organisation and provision of supportive care
services comply with the recommendations made in previous NICE guidance
documents (‘Improving outcomes in breast cancer: Manual update’ [2002] and
‘Improving supportive and palliative care for adults with cancer’ [2004]), in
particular the following two recommendations:
- ‘Assessment and discussion of patients’ needs for physical,
psychological, social, spiritual and financial support should be
undertaken at key points such as diagnosis at commencement, during,
and at the end of treatment; at relapse; and when death is
approaching.’
- ‘Mechanisms should be developed to promote continuity of care, which
might include the nomination of a person to take on the role of 'key
worker' for individual patients.’
Management of specific problems
 A breast cancer multidisciplinary team should assess all patients presenting
with uncontrolled local disease and discuss the therapeutic options for
controlling the disease and relieving symptoms.
 Offer bisphosphonates to patients newly diagnosed with bone metastases, to
prevent skeletal-related events and to reduce pain.
 Use external beam radiotherapy in a single fraction of 8 Gy to treat patients
with bone metastases and pain.
 Offer surgery followed by whole brain radiotherapy to patients who have a
single or small number of potentially resectable brain metastases, a good
performance status and who have no or well-controlled other metastatic
disease.
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5.3.6 Women requiring treatment for psychological morbidity
Up to one third of women with breast cancer will suffer from psychological morbidity,
which may have a detrimental effect on treatment compliance (125). Particularly high
levels have been demonstrated in women who have undergone mastectomy (126).
Generally, women who undergo BCT have a better body image but levels of anxiety
are still high (127). Improved psychosexual well-being has been associated with
breast reconstruction following mastectomy Maguire et al (129) demonstrated in an
RCT that a nurse counsellor was successful in identifying psychiatric morbidity in
women undergoing mastectomy. Subsequent referral to a psychiatrist resulted in an
overall lower level or morbidity in the intervention group a year later. The cost of the
nurse counsellor was offset by savings in psychiatric inpatient care and fewer days
off work by patient and carer (130). According to EUSOMA (44), it is recommended
that a breast care nurse or psychologically trained person be present to discuss fully
with the patient the options for treatment and to give emotional support. A suitable
room with sufficient privacy must be available. EUSOMA add that if a patient is
experiencing psychological abnormality that cannot be dealt with by members of the
Breast Unit, they should be referred to a psychiatrist with whom there are particular
arrangements to see breast patients. NICE (48) state that psychological support
should be available at every stage to help patients and their families cope with the
effects of the disease and a breast care nurse should be available for support and
counselling. The latest European guidelines (56) recommend that patient support
must be provided by specialist breast nurses or appropriately psychologically,
professionally trained persons with expertise in breast cancer. At least two of these
people are needed per breast unit. They must be available to counsel, offer practical
advice and emotional support.
Patients value adequate information on diagnosis and treatment within the contest of
a caring physician-patient relationship. According to NICE (48), at every stage of the
patient journey, individuals should be offered clear, objective, full and prompt
information in both verbal and written form and members of the breast team should
have special training in communication and counselling skills. The UK NHS Cancer
Services Collaborative/Improvement Partnership (108) state that the vast majority of
patients with breast cancer and their families/carers want information about their
condition, the treatments that are available and the side effects of their treatments.
They also need to know where and when the various investigations and treatments
are to take place so that they can arrange their lives and those of their families
accordingly. Local networks and voluntary organisations such as Cancer backup,
Cancer Voices and Macmillian Cancer Relief need to be engaged in this process.
However, they admit that there has been little formal evaluation of the best way of
imparting information within this relationship; methods currently used include leaflets,
videotapes, and written and taped recordings of consultations (132).
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Key Messages:
 Guidelines on breast cancer care include those from EUSOMA, NICE
Improving Outcomes, Welsh Assembly Government, BASO, the European
Union and recent draft NICE guidelines.
 Population based mammographic screening is effective in reducing
mortality from breast cancer by up to 30% in women aged 50 to 69. Costeffectiveness of mammographic screening is influenced by range of
factors. Guidance is that breast screening programmes should be based
within or closely associated with a recognised Breast Unit, which is already
the case in Wales.
 Women with a first degree relative with breast cancer have a three-fold
increased risk of developing the disease. These women should be provided
services according to NICE guidance, which WAG has recently endorsed.
 Consensus supports a triple assessment approach in assessment of
symptomatic women, which all Trusts provide.
 The role of MRI is under evaluation, although it has an established place in
the investigation of implant dysfunction, recurrent or multifocal
malignancy. NICE has recommended that women at increased risk of breast
cancer as a result of their family history be offered annual MRI scanning.
MRI is currently available on-site at all Units except for Llandudno Hospital.
 Recent draft NICE guidelines suggest that patients with early invasive
breast cancer should be offered DXA scanning in certain circumstances.
DXA scanning is only currently available on site in Llandudno Hospital.
 A Breast Unit must advise and where necessary treat women with benign
breast disease. Treatment of DCIS is by mastectomy or breast conservation
therapy. Two equally efficacious treatments for patients with Stage I or II
breast cancer are modified radical mastectomy or breast conservation
therapy, followed by radiotherapy. Pathological staging should be done to
direct decisions on adjuvant therapy. SLN Biopsy is a safe and effective
alternative to axillary dissection in trained hands. The gold standard
method involves injection of blue dye/ radioactive colloid and preoperative
lymphosctintogram; this is provided on-site currently at all Breast Centres
except for Llandudno Hospital and Countess of Chester (which has plans to
introduce in 2009).
 Evidence indicates that immediate breast reconstruction does not
adversely affect breast cancer outcome and has economic benefits,
produces better results than delayed reconstruction and reduces the
psychological morbidity associated with mastectomy. Guidance is that it
should be offered to women at the initial surgical operation and that an
oncoplastic breast service should normally be on site and constitute a core
component of the MDT.
 Routine F/U of women with treated breast cancer should be by routine
physical examination and yearly mammography; recent draft NICE
guidelines have suggested yearly mammography until age 70. A specialist
palliative service should be available for referral of cases of breast cancer.
 Up to one third of women with breast cancer will suffer from psychological
morbidity. Psychological support should be available at every stage to help
patients and their families cope with the effects of the disease and a breast
care nurse should be available for support and counselling.
 At every stage of the patient journey, individuals should be offered clear,
objective, full and prompt information in both verbal and written form and
members of the breast team should have special training in communication
and counselling skills. Local networks and voluntary organisations need to
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5.4 Organisation of Breast Care Services
The optimum configuration of services for women with breast disease is a prime
concern for NHS purchasers. Health gain may be maximised by (20):


early detection through mammographic screening
appropriate diagnosis and treatment of women with breast disease
It is important to identify the attributes of a service which may adversely affect the
survival of women with breast cancer and/or the positive experience of women
suffering from breast disease. These are described as follows:
5.4.1 Public Health Criteria
Public Health has been defined as: “The science and art of preventing disease,
prolonging life and promoting health through organised efforts of society” (134). In
order to advance these goals, any service remodelling should seek to develop
services which meet key population health criteria:

services of the highest possible quality;

services which are sustainable and well designed to cope with future changes
to the world in which we live;

services which present the least possible risk to the health of the population
they serve;

services supported by the systems by which they are provided;

services which enjoy the confidence of the people they are designed to serve.
5.4.2 Definition and Levels of Breast Unit
EUSOMA (44) defines a breast unit as ‘a group of specialists in breast cancer and
need not necessarily be a geographical single entity, although the separate buildings
must be within reasonable proximity, sufficient to allow multidisciplinary working’.
They estimate that for a 10 million population base 30-40 breast units are required
for the ideal service and that breast units they should generally cover one-quarter to
one-third of a million total population. Some highly specialised units will be larger.
The European guidelines (55) describe three levels of breast unit categorisation:


diagnostic breast imaging unit - only offers diagnostic mammography and/or
breast ultrasound and must perform mammographic examinations on at least
1000 women annually in order to be eligible for certification.
diagnostic breast assessment unit - a highly specialised unit which is required for
the workup of substantial clinical or imaging findings. Such a unit should perform
at least 2000 mammograms per annum, employ a trained radiologist reporting at
least 1000 mammograms per year, have specialist cytological and
histopathological support services, organise regular multidisciplinary review
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meetings, monitor data and feedback results and also keep formal records of
assessment processes and outcomes. Its specialist multidisciplinary team will
have access to more sophisticated imaging equipment and non-operative
diagnostic techniques than are available in a diagnostic breast imaging unit.
Sampling techniques may include fine needle aspirate cytology, core biopsy or
vacuum-assisted biopsy.
Specialist breast unit – a specialist multidisciplinary breast unit should be on the
basis of a population of at least 250,000 and should be subject to mandatory
quality assurance programmes. A unit should have >150 newly diagnosed cases
of primary breast cancer per year. The breast unit must have an identified clinical
director of breast services and each member of the core team must have a
specialist training in breast cancer. Two or more nominated breast surgeons must
be available, each personally carrying out primary surgery on at least 50 newly
diagnosed cancers per year and attending at least one diagnostic clinic per week.
There should be at least two nominated, fully trained and experiences
radiologists able to carry out all aspects of beast imaging, sampling and
localisation procedures under image control. They should read a minimum of
1000 mammograms per year or 5000 for those participating in screening
programmes. There should be a lead pathologist; clinical/medical oncologists
should carry out radiation therapy and prescribe chemotherapy as appropriate.
They should be members of the core team. The unit must possess suitable up to
date imaging and therapeutic equipment. Adjuvant therapies such as
radiotherapy or cytotoxic therapy may be given at separate clinics or hospitals to
the breast unit but such treatment may be supervised by the main breast unit and
all decisions made by the units multidisciplinary team. Facilities for pain
control/palliative care should be available. Women should have access to a
family history/genetic service.
5.4.3 Multidisciplinary care
A multidisciplinary model of care for breast cancer is an approach that encompasses
specialist team care and access to all potential treatment options suitable for
individual patients (135). It involves collaboration between team members and
treatment planning, and is more likely to be patient centred and to provide
psychological support an access to clinical trials. Houssami and Sainsbury give a
representation of this model in Figure 15:
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Figure 15: Model of Multidisciplinary care (135)
Houssami and Sainsbury performed a systematic review to assess the extent and
quality of evidence on whether multidisciplinary care, or related aspects of care,
contribute to clinical outcomes in breast cancer, and whether it particularly influences
survival. They concluded that although intrinsically multidisciplinary care should be
associated with better survival, there remains a paucity of evidence to support this.
However, it is an approach which is widely recommended for breast care services.
EUSOMA (44) state that all members of the core breast care team should attend a
multidisciplinary meeting, which must be held at least weekly. According to the UK
NHS Cancer Services Collaborative/Improvement Partnership (108), the vast
majority of Trusts now hold regular multidisciplinary team meetings. In fact, many
Trusts now include a sessional commitment to the breast cancer multi-disciplinary
team as part of the contract of employment of new consultants. It adds that
geographical problems (e.g. consultants working on different sites) can be
addressed by the use of high quality video links. All Trusts that provide a service to
North Wales residents hold weekly MDT meetings.
5.4.4 Staffing of Breast Units
Healthcare professionals and organisations involved in breast care services include
primary health care teams, public health professionals, surgeons, radiologists,
radiographers, breast care nurses, pathologists, medical and clinical oncologists,
psychiatrists and palliative care teams. Voluntary agencies and social services
provide information, psychosocial care and practical support. A number of guidelines
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have specified staffing requirements for breast units. According to EUMOMA (44)
each member of the core team should have special training in breast cancer and the
Breast Unit should have an identified Clinical Director of Breast Services. Each Unit
should have at least two or nominated surgeons specially trained in breast disease,
which is the case in North Wales. There should also be at least two nominated
radiologists, fully trained and with continuing experience in all aspects of breast
disease and associated imaging, tissue sampling and localisation procedures under
image control. A lead pathologist, plus usually not more than one other nominated
pathologist, specialising in breast disease, should be responsible for all breast
pathology and cytology. A nominated radiation oncologist must arrange the
appropriate delivery of radiotherapy. Radiographers with the necessary expertise
and training in mammography are also essential members of the team, as are breast
care nurses. Clinics to which patients are referred must be staffed by a surgeon, a
radiologist and radiographers from the breast care team. NICE (48) says that there
should be at least two specialists for each role in the core breast care team and each
of the individuals should dedicate at least 50% of their time to breast care. BASO
guidelines (51) recommend that constituent members of a breast team can be
divided into two separate but interdependent groups – the diagnostic team and the
cancer treatment team, as follows:

Diagnostic team – as most patients do not have breast cancer, the role of the
diagnostic team is to diagnose breast cancer and to treat and reassure
patients with benign breast disorders. The key component members of the
team are:
- Breast specialist clinician – only surgeons with a special interest in
breast disease should treat patients with breast cancer and breast
disease. There should be at least two of these per Breast Unit.
- Specialist radiologist and radiographer
- Pathologist and laboratory support staff
- Breast care nurse – should be available for all patients undergoing
treatment for breast disease. Ideally there should be two per breast
unit, and they should attend the MDT meeting.
- Clinic staff
- Administrative staff

Cancer treatment team – this may include members of the diagnostic team as
well as the following:
- Clinical oncologist
- Medical oncologist
- Plastic and reconstructive surgeon
- Medical geneticist
- Data management personnel
- Research nurse
- Lymphodema specialist
- Medical prosthetist
- Clinical psychologist
- Palliative care team
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Connected with staffing of Breast Units is the European Working Time Directive. This
directive, due to be implemented in 2009, affects the number of hours junior doctors
can work (48 hour week). If current working hours stay the same, a large increase in
the number of doctors would be needed to run a 24 hour service. This would mean
particular problems for smaller hospitals with limited staff.
5.4.5 Geographical Location of Breast Units
The evidence base in relation to rural and remote communities shows that there is a
decline in access to services with increasing distance from medical care, and poorer
health outcomes of remove rural residents (136). NICE (48) emphasises that there
should be equity of access for all breast care patients.
A Policy Framework for Commissioning Cancer Services (137) recommends that the
breast cancer unit should usually be based in the District General Hospital but with
the proviso that where hospitals are adjacent to one another, it might be more costeffective for only one to provide breast care. Furthermore, in geographically isolated
units. multidisciplinary consultation by telemedicine might be appropriate. There
appears to be good evidence to support the use of telemedicine in linking clinical
networks in pathology, cancer and psychiatry (136). EUSOMA (44) state that Breast
Units will most often be established in large or medium sized hospitals and that the
Breast Unit should hold outreach clinics for symptomatic referred women, screening
assessment and follow-up in the smaller hospitals in the neighbourhood if these are
at a distance from the Breast Unit. In areas with low population density, out-reach
arrangements are preferable to the establishment of small breast units without the
clinical volume to allow expertise. In that circumstance, outreach clinics may be held
as infrequently as one per month.
5.4.6 Facilities available to Breast Units
EUSOMA (44) recommends that Breast Units must provide care of breast diseases
at all its stages. To this end, the unit must be in possession of all necessary imaging
equipment for complete and adequate breast analysis. There should also be rapid
access facilities for bone scanning and other imaging, including MRI.
According to BASO (40), the breast diagnostic process should be carried out in a
designated breast clinic, which should provide an environment that allows efficient
multidisciplinary clinical practice while providing privacy for individual patients.
Adequate consulting and examination rooms should be available to allow patient
privacy, permit efficient working practice and enable discussion with breast care
nurses and trainees. A unit with a consultant, registrar, clinical assistant and a breast
care nurse should have three consulting rooms, six examination rooms and a
separate room for the breast care nurse. The whole team should be accommodated
in a single clinic unit and not dispersed across different departments or floors.
Ideally, radiology resources should be located close at hand with adequate space for
mammography, ultrasound and reporting. If desired there should also be space for
accompanying pathology facilities such as a room for a cytology mini-lab,
microscope, consultant pathologist and MLSO. If the cytology facilities are not
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included in the immediate clinic environment, adequate portering facilities should be
available to permit rapid transport to the pathology laboratory.
It also recommends that breast cancer treatment should be offered in a pleasant and
appropriate physical environment. There should be private areas available where
patients and staff can discuss diagnosis and treatment, where patients can be
counselled without being interrupted, and space for each woman to be accompanied
by a friend or relative. Attention should also be paid to privacy in changing facilities,
arrangements for fitting of prostheses, availability of refreshments, and proximity and
privacy of toilets. Single-sex wards or bays should also be available.
5.4.7 Size and Specialisation of Breast Units/ Workload of consultant surgeons
Hospital and specialist caseload and/or specialisation have been shown to be
associated with improved breast cancer survival in a number of studies (138-145).
Hospitals
There is little evidence to support a beneficial impact of specialist hospitals on
survival of women with breast cancer. Two studies in Italy and Australia have failed
to demonstrate a significant difference in survival between women attending private
institutions compared to public hospitals (146,147). Although Karjalainen (148) did
find a higher survival among Finnish women with breast cancer resident in districts
with a university teaching hospital with radiotherapy facilities, this was confined to
women with advanced disease. Lee-Feldstein et al demonstrated a significantly
better survival amongst US women with breast cancer treated in larger community
hospitals compared to those treated in smaller community and Health Maintenance
Organisations even after adjustment for other factors known to influence survival.
Basnett et al (150) showed that women resident in a London district hospital district
with a teaching hospital were more likely to undergo BCT, axillary node surgery and
adjuvant chemotherapy than those resident in a district without a teaching hospital.
In terms of case volume, Roohan et al (151) reported that breast cancer patients
treated in a very low volume hospitals (<10 surgeries per year) had a greater risk of
mortality than patients in high volume hospitals (more than 150 surgeries per year).
They also found that patients treated in hospitals with low (11-50) and moderate (51150) had a higher risk of dying (30% and 19% respectively) than patients in high
volume hospitals. Skinner et al evaluated 5-year survival by annual hospital volume
which showed 84% in high volume (>125), 82% in medium volume (71-125), 78% in
small volume (36-70) and 75% in very small volume (<35). The hazard ratios for
each hospital category compared to the very small volume category were 0.77 for
high volume hospitals, 0.78 in medium-volume hospitals and 0.92 in small-volume
hospitals. They also reported that patients who had undergone surgery at hospitals
where >125 breast cancer surgeries were carried out each year were more likely to
achieve long-term survival. In contrast, Harcourt and Hicks reported that survival for
breast cancer between 1980 and 1994 did not correlate with hospital case volume
(P=0.40). A recent study from Japan (153) looked at survival in high-volume, medium
volume, low volume and very low volume hospitals. They concluded that the surgical
volume of hospitals did not affect the 10-year survival rate significantly, except for
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very low hospitals (<15 surgeries per hospital per year). NICE (48) state that higher
patient volumes are believed to be associated with greater accuracy of diagnosis,
better quality treatment and better survival rates for patients. EUSOMA guidelines
and the latest European guidelines (55) set a caseload per breast unit of at least 150
new breast cancers per annum. According to Mansel (154), this figure is not
supported by direct evidence but is based more on consensus and cost, as the
multidisciplinary team approach is expensive in people and equipment and would be
less suitable for a low caseload clinic. In contrast, NICE (48) recommends that all
breast referrals should be to specialist breast teams working in units which deal with
at least 100 new cases of cancer per year (a level which may be anticipated from a
population of about 200,000 people). It admits that this figure is rather ‘arbitrary’.
This throughput figure should apply to the breast team as a whole (which may
operate across more than one hospital) rather than to individual members or the
whole institution. NICE adds that in areas that are sparsely populated and
geographically remote, there may be a trade-off between the quality of the service
and ease of access. There should be a defined arrangement with a properly
constituted team whereby patients or patients are moved to agreed locations for
breast cancer care. SIGN (50) endorses that Units normally seeing at least 100 new
cases of breast cancer per annum should be able to maintain their expertise. In
areas with low population densities, formal collaborative links between adjacent
larger units/centres should give patients access to all necessary facilities as well as
helping to maintain expertise in the smaller unit. If two hospitals are close together it
is more practical for only one of them to establish a functional breast unit serving
both hospitals i.e. the breast team works at both centres. All Breast Units serving
North Wales residents see more than 100 new cases of breast cancer per annum,
and most see more than 150 cases.
Clinicians
The most consistent evidence of a survival benefit is in studies of specialist
(surgeon) effect (both caseload and specialisation). This may be due to better
surgical management (both selection and surgical technique), greater use of
adjuvant therapy or more appropriate use of a multi-disciplinary approach (hence
appropriate selection of treatment options that are more likely to confer clinical
benefits. The observed differences in survival in several of the studies identified in
their review was relatively high – a proportional improvement in survival (in relation
to caseload or specialisation) of up to 30%.
There exists a strong belief that only those surgeons with a significant caseload of
women have the skills necessary to manage breast cancer (155). Hand et al (156),
for example, reported a significant association between failure to deliver radiotherapy
for early beast cancer and number of cases treated. However, uncertainty exists as
to the volume of new cases necessary to maintain competence but a notional figure
of 50 has been suggested (157). A population based audit of breast cancer in
Yorkshire has demonstrated that survival was better among women treated by
surgeons who had a caseload in excess of 30 breast cancers per year. EUSOMA
(44) recommend that each breast surgeon should personally carry out the primary
surgery on at least 50 newly diagnosed cancers per annum and must attend at least
one diagnostic clinic per week. NICE (48) states that clinicians who provide
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treatment should seen at least 50 new patients with breast cancer each year. BASO
(40) guidelines are that consultant surgeons should normally have a minimum
caseload of 30 new breast cancer patients per year on average and a maximum of
150 new cases per year. European guidelines (55) refer to more than 50 cases per
annum. Although caseload figures for individual surgeons are not available for North
Wales, it is likely that they all see more than 50 new breast cancer patients per year.
5.4.8 Referral Process
NICE (48) recommends that each primary care team should include at least one
practitioner who has had specific training in carrying out clinical breast examination
in women with breast symptoms and that all patients with possible breast cancer
should be referred to a breast clinic without delay. According to BASO guidelines
(40), the process of referral from primary care should be simple and clearly identified
to permit urgent referral. Local referral guidelines for breast cancer should be agreed
and disseminated by cancer networks. NICE (48) set out criteria for referral as
follows:


Urgent referral (within 2 weeks): Patients aged 30 and over with a discrete
lump in the breast. Patients with breast signs or symptoms which are higher
suggestive of cancer such as ulceration, skin nodule, skin distortion, nipple
eczema, recent nipple retraction or distortion, unilateral nipple discharge
which stains clothes.
Conditions which require referral, not necessarily urgent: discrete lump in
a younger woman, asymmetrical nodularity that persists at review after
menstruation, abscess, persistently refilling or recurrent cyst, intractable pain
which does not respond to simple measures, nipple discharge such as
bilateral discharge sufficient to stain clothes or blood stained discharge in
women under 50 or any nipple discharge in patients over 50.
According to the UK NHS Cancer Services Collaborative/Improvement Partnership
(108), there are various methods of referral to specialist breast clinics in the UK, the
majority letters or phone calls. They describe how the introduction of a fax referral
proforma, which identifies clearly the criteria for referral, enabled a reduction in the
number of steps from the GP to the specialist clinic appointment from 20 to 5. BASO
guidelines (40) recommend that all clinic letters should be sent to general
practitioners within one week of the clinic and all new diagnoses of breast cancer to
be communicated to the GP within 24 hours.
5.4.9 Delay in diagnosis
There is no definitive evidence supporting the proposition that delays in diagnosis or
referral routinely experienced within the NHS adversely influence survival (20).
However, NICE (48) emphasises the importance of minimising delay in breast care.
In an attempt to reduce diagnostic delay and the frequency of hospital visits, rapid
diagnosis (or one-stop) clinics have been introduced worldwide. In a typical one-stop
clinic, women have a mammography in the screening assessment unit, after which a
consultant radiologist could perform ultrasoundography. A consultant surgeon
assesses patients when imaging reports are available. Women undergoing
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aspiration cytology wait while this is reviewed by the consultant pathologist. The
surgeon then reassesses patients and discusses their management. An example of
a one-stop breast clinic in the UK is at the Queen Elizabeth Hospital, Gateshead
(164), established in 1997. There are four clinics per week that follow the triple
approach
for
diagnosis
consisting
of
physical
examination,
mammography/ultrasoundography, and fine-needle aspiration cystology in all one
sitting. In order to obtain rapid and accurate assessment, patients fill out a
questionnaire that records relevant medical history. A proforma is filled out by the
clinician, which records the history of breast complaints and examination findings.
The consultant radiologist reports on imaging and the consultant pathologist provides
cytologic assessment (Fine needle aspiration cytology and core biopsy). Kalbassi et
al (164) studied 2535 patients seen in their one-stop clinic between June 1 2001 and
July 31 2002 and reported that the majority of patients (86.6%) were assessed,
treated or reassured, and discharged in one day. The paper also mentions that the
clinics involve workload equivalent to 27 clinics for normal cases, 17 clinics for breast
pain, 16 clinics for diffuse nodularity and 20 clinics for cysts, with a total of 22
patients per clinic. The staff wages per clinic were found to be 950 pounds (42 per
patient). They conclude that the one-stop clinic is an important tool for diagnosis,
rapid management and reassurance of patients with breast disease.
Although prolonged investigations can reinforce patients concerns (165), two studies
have shown that women diagnosed with breast cancer at a one-stop clinic are at
greater risk of adverse psychological sequelae than women attending more than
once secondary to an expedited diagnosis of malignancy. One demonstrated this
effect only in women with confirmed malignant disease 8 weeks after diagnosis (166)
and another study showed a similar delayed effect but did not present data by
malignant or benign diagnosis (167). However, Harcourt et al (166) also showed that
women with a benign result who had received their results at a one-stop clinic were
significantly less anxious six days later than those in the two stop system, who were
still awaiting their results. No difference was detected in anxiety levels at this point in
women with breast cancer who had been given their results and those who has not.
According to NICE (48), an audit of patient views of a one-stop clinic recorded high
levels of satisfaction and the evidence that a two-step system reduces the
psychological impact of the diagnosis of breast cancer eight weeks later cannot be
regarded as reliable. One disadvantage of one-stop clinics is that they must be
provided by consultants because women are seen only once, and throughput is less
because more time is needed to discuss findings and management, and consultant
radiologists and pathologists must be available for the whole clinic although not
always needed. Rapid diagnosis clinics may also lead to relaxation of referral criteria
by GPs.
In terms of guidelines, SIGN (50) concludes there is evidence that one-stop
symptomatic clinics provides an accurate and effective means of establishing a
correct diagnosis in women referred with breast symptoms. EUSOMA (44)
recommends that all standard investigations for triple assessment (clinical
examination and all appropriate imaging and tissue diagnostic procedures) should be
completed at one visit. Where possible the finding of no abnormality or a confirmed
diagnosis of a benign lesion should be communicated to the patient at that visit.
However, women found to have breast cancer should receive their diagnosis within
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five working days and this should be communicated by the surgeon. NICE (48) says
that facilities and staff for triple assessment should be in close proximity, and
diagnostic services must be able to provide rapid and accurate information on
imaging results and tissue samples, but falls short of endorsing ‘one-stop clinics’. It
repeats that results should be given within 5 working days to patients. Although
BASO (51) mentions that in ideal circumstances, all patients with benign breast
disease should received all required tests and be informed of the results in a single
visit to the clinic, they add that core biopsy is increasingly used in assessment to
provide information on the presence or absence of invasive tumour, allowing
provisional assessment of tumour type and grade and enable tumour marker
analysis. Interpretation of a core biopsy cannot be performed within the time
constraints of a single clinic. In addition, the days between clinic visits can allow
formal assessment and discussion of suspected cancer diagnoses in the
multidisciplinary meeting, prior to a second clinic visit where the patient is informed
of the diagnosis and the appropriate treatment options. The 2008 European
guidelines (55) recommend that to minimises anxiety and delay, women should be
fully assessed in three visits or less. Also that the provision of rapid diagnostic clinics
where skilled multidisciplinary advice and investigation can be provided is
advantageous for women with substantial breast problems in order to avoid
unnecessary delays in outline of management planning or to permit immediate
discharge of women with normal/benign disease. It is our understanding that onestop clinics are currently provided by all the Trusts serving North Wales patients.
5.4.10 Ambulatory Breast Surgery
The standard treatment for most women with breast cancer is excision of the primary
tumour (with wide local excision or mastectomy) with axillary lymphadectomy (168).
Suction drainage of the axilla is standard practice to prevent seroma formation but
practice varies about the length of time required for axillary drainage with patients
frequently having a hospital stay of 5-8 days (169). It has been suggested that
ambulatory surgery would be advantageous for breast cancer. An ambulatory
surgical procedure is one in which the whole process is complete within 24 hours
(170). This includes same day procedures, when admission and discharge are on
the same day, although the whole process is complete within 12 hours and one day
procedures, when an overnight stay is required, but it is less than 24 hours
(171,172).
Ambulatory breast surgery has been widely used in the USA and most of the
literature on this topic is from this country, where it is acknowledged that the heath
system differs significantly from our own. In 1998, Warren et al (173) found that the
proportion of mastectomies performed on an outpatient basis in the US had
increased by 0 to 10.8% between 1986 and 1995. They also discovered that for both
simple and modified radical mastectomies, women undergoing outpatient surgery
experienced rates of rehospitalisation for conditions definitely related to their surgery
comparable to those for women with a one day hospital stay. They concluded that
the risks from outpatient mastectomy are modest. This type of surgery has gradually
been introduced to Europe. In 2004, a questionnaire was sent to 105
surgeons/hospitals in the Netherlands enquiring to what extent day case surgery for
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breast cancer is practiced. 30% of hospitals reported that they performed minor and
3% major breast surgery in a day case setting. However, 16% of the hospitals
indicated that they planned to introduce day case surgery for minor and major breast
cancer surgery (174). In the UK, day case axillary node surgery (ALNS) for breast
carcinoma has been performed at the University Hospital of North Tees for over 6
years (168). When patients are seen in the breast clinic, their ability to undergo daycase surgery is assessed by ensuring that there is no significant medical comorbidity, full mobility and the presence of a carer to supervise following discharge.
They are reviewed immediately after the breast clinic recommendation for surgery by
day-case unit nurses for surgical preassessment. Prior to discharge, the ability of
patients to perform the activities of daily living, toleration of a full diet and adequate
pain control with oral analgesia is confirmed.
In the USA, Dooley (175) developed what he termed an ‘ideal surgical treatment
experience’ for ambulatory mastectomy based on extensive satisfaction surveys at
the university of Oklahoma Breast Institute. All patients and their family are
counselled prior to surgery and encouraged to participate in active treatment
decisions about breast conservation versus mastectomy using traditional resources,
but also preoperative and postoperative photos and survivor comments about the
surgical process. On a preoperative teaching day, in addition to traditional laboratory
and radiological testing, all are taught drain and wound care techniques, arm
exercises, and lymphodoema precautions. On the operative day, a detailed schedule
is developed for the patient and family. In terms of anaesthesia, most patients were
managed with nasal cannula or green mask oxygen and sedation to supplement the
local alone. Patients and their families are encouraged to make the decision to stay
overnight or go home after becoming ambulatory in recovery.
A number of studies over the last decade have found that ambulatory breast surgery
can be safe and effective. Tan and Guenther (176) looked at 100 consecutive
women undergoing definitive breast surgery, concluding that breast cancer surgery,
from axillary lymph node dissection with or without concomitant partial mastectomy
(ALND), simple mastectomy (SM) and modified radical mastectomy (MRM) can be
safely and comfortably performed on an outpatient basis. Margolese and Lasry (177)
conducted a study to compare inpatient to ambulatory surgery for breast cancer in
terms of psychological distress, pain, anxiety, quality of life, emotional adjustment,
recovery, social relations and stressful life events. They found that day case and
inpatients reported similar levels of pain, fear, anxiety, health assessment and quality
of life. In addition, day-case patients had better emotional adjustment post-op and
exhibited fewer psychological distress symptoms. Inpatients reported that it took an
average of 27 days to feel that they had recovered from surgery, about 10 days
longer than day-case patients. Inpatient returns to usual activities was also about 11
days later. The researchers concluded that day-case patients are not at a
disadvantage compared to hospitalised patients in that they report faster recovery
and better psychological adjustment. Also that outpatient surgery may foster patient
emotional well-being to a greater degree than routine hospitalisation. Dooley (175)
examined 92 ambulatory primary breast cancer surgical procedures performed in 87
patients; 64 patients underwent breast conserving surgical procedures and 23
underwent mastectomy. Only one patient chose to stay in the centre overnight. All
others were discharged in less than 2.5 hours postoperatively. Dooley therefore
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concluded that his detailed approach to ambulatory mastectomy, described
previously, can result in markedly reduced healthcare costs without incurring
additional morbidity or mortality. The objective of a study by Athey et al (168) was to
determine the safety, tolerability and efficacy of day-case surgery without suction
drainage. Between 2000-2002, 165 patients underwent intended day-case axillary
surgery. 29 of these (17.6%) underwent axillary dissection alone, the remainder
axillary surgery compared with wide local excision. Complications included seroma
formation in 37 patients (22%) and wound infection in 16 patients (10%). The
authors concluded that day case axillary surgery can be performed safely with
surgical morbidity comparing favourably to published work of ‘traditional’ axillary
drainage following lymphadenectomy. Marchal et al (170) looked at the patient
information provided, the management of post-operative symptoms and postoperative care, and patient satisfaction with 236 patients undergoing day-case breast
surgery. 169 of these patients underwent wide local exicision and 50 wide local
excision and axillary lymphadectectomy. They found that 38 patients remained in
hospital for one night after surgery due to nausea, anxiety, pain or bleeding. The
main symptoms on discharge were tiredness and pain. Patients experienced more
pain when an axillary lymphadenectomy had been performed (p<0.001). The mean
overall satisfaction score was 8.97 on a scale of 1-10. The authors concluded that
ambulatory surgery for breast cancer is safe and popular with patients, but that postoperative pain presents a problem. They noted that because of the potential of
conversions from ambulatory care to an overnight stay, the infrastructure of premises
must enable easy transfer of patients from an ambulatory unit, which closes in the
evening, to a traditional hospital ward. In 2005, Carcano et al (178) examined the
feasibilty and efficacy of outpatient treatment for 32 women treated for early breast
cancer in their department of surgery in Italy. They concluded that ambulatory
surgery for early breast cancer is feasible, effective, safe, as well as satisfactory for
patients in the Italian context. Marrazzo et al (96) recently reported their experience
with conducting quadrantectomy and SLN Biopsy in day surgery for 100 patients with
early breast cancer. None of the patients required readmission and all patients were
found to be satisfied with early discharge from hospital on subsequent questioning.
They also found that recovery from surgery is faster and fewer than one half of
patients required another surgical procedure, concluding the surgery in a single
session.
Ambulatory breast surgery has been shown to be more cost effective than standard
surgery. An economic analysis estimating the cost reduction in the acute care setting
and the required investment in the home care setting of implementing an outpatient
/early discharge strategy for Stages 1 and II breast cancer in Canada was published
in 2000 (179). The model assumed that this approach would be appropriate for 90%
of patients, compared outpatient breast conserving surgery and 2 days of
hospitalisation for those women undergoing mastectomy; a 5% readmissions rate for
hospitalisations was assumed. The cost of initial treatment for the 15,399 women
diagnosed with Stages I and II breast cancer in 1995 was estimated at 1276 million
Canadian dollars; hospitalisation made up 53% of these costs. Under the
outpatient/early discharge strategy, the acute care cost of initial breast cancer
management could be reduced by 47.2 millon, with an investment in home care of
14.5 million (453 per patient). This resulted in a net saving of 33 million. They
concluded that if ambulatory breast cancer surgery was widely adopted and if
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resources were redirected to the provision of home-based post-operative care, there
would be potential for a large net healthcare saving and the preservation of high
quality patient care.
Bian et al (180) examined the association between outpatient mastectomy in the
USA and the likelihood of post-mastectomy reconstruction, controlling for patient
characteristics. The proportion of patients receiving reconstruction were 13% for
inpatient mastectomy patients and 4% for outpatient mastectomy patients and
multivariate regression analysis suggested that outpatient mastectomy patients were
less likely to receive reconstruction (odds ratio =0.247; 95% confidence interval (CI
0.166-0.368).
Ambulatory breast surgery is not part of the service currently provided to North
Wales residents.
5.4.11 Continuity of Breast Care
A Swedish study (180) compared two models of care for breast cancer patients with
regards to the patients’ perceived well-being. In the established care model, patients
were admitted to the ward the day before surgery and chose to stay until the axillary
drain was removed. Several surgeons and nurses were responsible for their care. In
the other model, there was a design of continuity care including an outpatient,
surgical, breast clinic for all patients with breast cancer. A particular surgeon and a
nurse had a certain responsibility for the care before, during and after the patients’
hospital stay. Continuity between the patient and the surgeon was stressed, as well
as the supply of information and psycho-social issues. The researchers found that
the care model with high personnel continuity had a positive effect on the patient’s
emotional state, mental well-being and perception of postoperative pain evaluated
one year after surgery.
5.4.12 Integrated Care Pathways and Clinical Guidelines (182)
Integrated care pathways are care plans that detail the essential steps in the care of
patients with a specific clinical problem and describe the expected progress of the
patient. They aim to facilitate the introduction into clinical practice of clinical
guidelines and systematic, continuing audit into clinical practice. They can also
provide a link between the establishment of clinical guidelines and help in
communication with patients by giving them access to a clearly written summary of
their expected care plan and progress over time. Despite the sound principles which
underlie integrated care pathways, few evaluations have been done of the cost of
developing and implementing them and their effectiveness in changing practice and
improving outcomes. The model care pathway from the UK NHS Cancer Services
Collaborative/Improvement Partnership (108) is shown in Figure 16 and is similar to
the North Wales Care Pathway:
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Figure 16: Model Care Pathway for Breast Cancer
A systematic review undertaken by Grimshaw and Russell (183) concluded that
specific guidelines do improve clinical practice. However, the size of improvements
in performance can vary considerably and significant advances can only be achieved
if guidelines are developed, disseminated and implemented in an appropriate
manner. An Effective Health Care Bulletin (184) has summarised the evidence
based on 44 systematic reviews and concluded that guidelines that were locally
relevant, disseminated actively and implemented by patient specific reminders
relating to professional activity are more likely to be effective. According to BASO
guidelines (51) local referral guidelines for breast cancer should be agreed and
disseminated by cancer networks.
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Key Messages:
 Acute services remodelling should seek to develop services which
meet key population health criteria such as services of the highest
possible quality, services which are sustainable and well designed to
cope with future changes to the world in which we live; services
which present the least possible risk to the health of the population
they serve; services supported by the systems by which they are
provided and services which enjoy the confidence of the people they
are designed to serve.
 European guidelines describe three levels of Breast Unit - Diagnostic
Breast Imaging Unit, Diagnostic Breast Assessment Unit and
Specialist Breast Unit.
 Guidance recommends that MDT meetings are held by the Breast
Unit at least weekly, which occurs in North Wales.
 Recommendations exist around appropriate staffing of breast units.
Each breast Unit should have at least two consultant surgeons
specially trained in breast disease, for example, which is the case in
North Wales.
 The evidence base in relation to rural and remote communities shows
that there is a decline in access to services with increasing distance
from medical care, and poorer health outcomes of remove rural
residents. There is little direct evidence around the geographical
location of breast units.
 Breast Units should have appropriate facilities for diagnosis,
treatment and follow-up. There should be rapid access facilities for
bone scanning and other imaging, including MRI. Attention to be paid
to patient privacy, with single sex wards or bays.
 Specialist and hospital caseload and/or specialisation have been
shown to be associated with improved cancer survival. It is
recommended that Breast Units should see at least 100-150 new case
of breast cancer per annum and breast surgeons should see at least
30-50 new cases of breast cancer per annum, and no more than 150.
These recommendations are likely to be fulfilled by the current
service.
 Each primary care team should have at least one practitioner who
has had specific training in breast examination. There should be
rapid referral of patients from primary care to a Breast Unit.
 Studies have shown benefits of one-stop clinics for breast cancer,
although new technology is making it difficult for patients to be fully
assessed in one visit. Patients should be fully assessed in three
visits or less. It is our understanding that North Wales patients
currently have access to one-stop shop clinics at all Units.
 There is good evidence that ambulatory breast surgery can be both
safe and effective but it is not currently provided in North Wales.
 There should be continuity of care and care pathways and referral
guidelines should be used in breast care services.
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5.5 Summary of Service Gaps
Tables 32-35 in Appendix 7 details compliance against standards including: National
Breast Cancer Standards; EUSOMA Guidelines/Recommendations; NICE Guidance
on Cancer Services – Improving Outcomes in Breast Cancer 2002, and the BASO
Guidelines. Information on this section has been provided by the North Wales
Cancer Network Director. It can be seen that all Trusts are broadly compliant with
these standards. Exceptions are detailed within the relevant tables. The Countess of
Chester is not subject to Welsh Standards but is compliant with English Accreditation
system which reflects Welsh Standards.
Table 36 in Appendix 8 details compliance against features expected in a modern
breast unit taken from the Holcolme and Rayner report (1) which agrees largely with
those found in the literature review. It can be seen that no hospital, particularly
Llandudno Hospital, currently provides all the elements of a modern breast care
service using the descriptors referred. As we have seen, a particular gap for all
Trusts is access to a comprehensive on-site reconstructive/oncoplastic service. In
addition, access to MRI is not available on-site at Llandudno Hospital (which does,
however, have DXA scanning available). Sentinel Node Biopsy with injection of blue
dye/ radioactive colloid and preoperative lymphoscintogram (the gold standard
method) is not currently available in Llandudno Hospital and Countess of Chester
(although the latter plans to introduce this in 2009). HDU/ITU services are currently
provided only at the three main acute hospital sites across North Wales.
5.6 Options for Breast Care Services in North Wales
Possible options for configuration of symptomatic breast care services in North
Wales, using the types of unit described in the fourth edition of the European
guidelines for quality assurance in breast cancer screening and diagnosis (55) are
shown in Table 37. These options are based on the following assumptions:




By 2011-15, it is predicted that there will be approximately 680 new cases of
breast cancer per annum in North Wales residents (based on average of two
WCISU predictions); there are currently about 6,000 symptomatic
mammograms done every year for North Wales residents.
Only Specialist Breast Units and Diagnostic Breast Assessment Units will be
needed in North Wales, rather than the smaller Diagnostic Breast Imaging
Unit
Specialist Breast Units should see a minimum of 150 cases per annum and a
minimum of 2,000 symptomatic mammograms per year. Diagnostic Breast
Assessment Units should perform at least 2000 symptomatic mammograms
per annum. A maximum of 4 Units (Specialist Breast Units/and or Diagnostic
Breast Assessment Units) excluding Countess of Chester are needed for the
North Wales population.
The Countess of Chester will continue to serve the Flintshire population.
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Table 37: Possible Options for Symptomatic Breast
Care Services
Option
No Specialist
No Diagnostic Breast
No.
Breast Units
Assessment Units
Serving North
Serving North Wales
Wales Population
Population
1
1
0
2
1
1
3
1
2
4
1
3
5
2
0
6
2
1
7
2
2
8
3
0
9
3
1
10
4
0
It should be noted that these options are not comprehensive and there are other
ways in which breast care services could be organised e.g. by performing diagnosis
and routine surgery in one unit, but more complicated surgery in another.
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6.0 Summary and Conclusions
6.1 Healthcare Needs Assessment
Breast cancer is the most common cancer in women in the UK. There are 2500
cases of female breast cancer in Wales every year. There has been a steady rise in
the incidence of breast cancer in the UK, though mortality from the disease has
fallen since 1989. Survival from breast cancer in the UK has improved significantly
over the last three decades.
Risk factors for breast cancer include old age, early menarche, late first pregnancy,
low parity, and late menopause, which are not amenable to primary prevention.
Alcohol consumption is associated with an increased risk of breast cancer, and
avoidance of obesity after menopause may decrease the risk of breast cancer..
Women who breast feed are less likely to develop breast cancer. About 5% of breast
cancer has a genetic origin.
The population of North Wales, currently 670,000, is predicted to increase to almost
700,000 by 2028. The next 20-30 years are likely to see a large growth in the
number of older people in North Wales which will have an impact on breast cancer
rates in the population, as one of the main risk factors for the disease is old age. The
incidence of breast cancer has increased in all LHB areas in North Wales over the
last 10 years, although the gap between the counties has narrowed in this period.
Predictions by the Welsh Cancer Intelligence & Surveillance Unit are that breast
cancer in the region is likely to increase by between 15% and 36% by 2016-20.
In general, mortality from breast cancer is higher and survival is lower in more
deprived communities. Tackling health inequalities remains a key issue in North
Wales, with almost one fifth of the population living within the most deprived wards in
Wales being located within North Wales local authority boundaries (notably in
Gwynedd and Wrexham). Deprivation is also accentuated by the rural nature of
much of North Wales and the relatively poorly developed road system, which can
make geographical access to health services an issue.
Breast Test Wales screens approximately 20,000 women each year in North Wales
and detect on average 200 cancers. It is therefore important that screening services
for the whole population are appropriately considered in any redesign of breast care
services, as healthy women comprise the vast majority of women presenting to
services. Round 5 breast screening uptake in North Wales was lower than the Welsh
average. Within North Wales, the screening uptake rate was lowest in Denbighshire,
and highest in Anglesey.
It is estimated that there are at least 25,000 women under the age of 65 in North
Wales who will develop benign breast disease in their lifetime. The highest
proportions of these are currently resident in Flintshire and the lowest in Anglesey.. It
is therefore important that women with benign breast disease are considered in any
redesign of the breast care service for North Wales residents as they comprise the
vast majority of women with breast disease.
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Wales has the second highest rate of breast cancer in the UK, as well as the second
highest mortality rate. There are, on average, 565 cases of breast cancer per year in
North Wales and the overall standardised incidence rate in North Wales is higher
than the Welsh average. There are, on average, 179 deaths from breast cancer in
North Wales every year and again this is higher than the Welsh average. Both these
statistics signify that North Wales has a greater need for breast cancer services than
Wales in general. Survival from cancer is, in general, better in North Wales. Five
year relative survival from breast cancer in North Wales is lowest in Anglesey,
Gwynedd, and Denbighshire, and highest in Flintshire.
Overall, the greatest overall burden of breast cancer in North Wales (and so the
greatest relative need for service provision) is in the counties of Conwy and
Gwynedd, which have the second and third highest number of cases of breast
cancer in North Wales, the highest standardised rates of breast cancer incidence,
the highest mortality (both in overall numbers and standardised rates). Flintshire also
has high relative need for service provision, as it has the highest absolute number of
breast cancers and the third highest number of deaths from the disease.
The analysis of hospital activity data for breast cancer has yielded interesting results.
Admission rates in North Wales were about half those in Mid & West Wales and less
than one third those in South-East Wales; within North Wales, rates were highest in
Denbighshire and lowest in Anglesey. Rates of bed use were highest in Gwynedd
and lowest in Wrexham; rates in North Wales were less than those in Mid & West
Wales but greater than those in South-East Wales. Average length of stay was
highest in Anglesey, lowest in Wrexham, and North Wales rates were higher than
those in Mid & West Wales and significantly higher than in South-East Wales.
However, it should be noted that the significant differences in admission rates, rates
of bed use and average length of stay between South-East Wales and the other two
regions may well be due to differences in data collection (including procedural
coding) and require further investigation.
Lifestyle and risk behaviour remains an important issue to address across the North
Wales population. For example, levels of alcohol consumption are highest in
Flintshire, consumption of fruit and vegetables are lowest in Wrexham, physical
activity levels are lowest in Flintshire and levels of overweight of obesity are highest
in Flintshire. All these factors are amenable to primary prevention. The North Wales
health community in collaboration with key partners need to work hard to improve the
understanding of risk factors and lifestyle behaviour in the North Wales population.
6.2 Current breast care service provided to North Wales
The current breast care service to North Wales residents is provided by North West
Wales NHS Trust (NWWT) via Ysbyty Gwynedd (YG) and Llandudno Hospital sites,
North Wales NHS Trust through Ysbyty Glan Clwyd (YGC) and Wrexham Maelor
Hospitals and the Countess of Chester Hospital. Breast screening is provided by
Breast Test Wales, a national screening service. Whiston Hospital Plastic Surgical
Unit provides a tertiary referral centre for breast plastic surgery.
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Breast Test Wales provides a high quality breast screening service with a high
Standardised Detection Ratio for breast cancer from its two static centres in
Llandudno and Wrexham, as well as three mobile units. Breast Test Wales
undertake weekly independent MDT activity in relation to patients receiving
screening services.
In 2006, North West Wales NHS Trust had the highest number of referrals for North
Wales patients with breast cancer, followed by Wrexham Maelor and Ysbyty Glan
Clwyd. North West Wales NHS Trust also diagnosed the greatest number of breast
cancers.
In terms of case volumes, all Trusts saw more than 100 new breast cancers per year
and most see more than 150. Currently, all Trusts hold weekly MDT meetings, MDT
core membership is compliant and attendance is good for all Units. All Trusts have
the full range of extended team members (although virtually none of these report that
they routinely attend MDT meetings). All the breast cancer teams are compliant with
the cancer waiting times.
6.3 The Breast Care Patient Journey
Guidance that has been produced around breast cancer care includes that from
EUSOMA, NICE 2002, Welsh Assembly Government, BASO, European Union and
recent draft NICE Guidance.
Population based mammographic screening is effective in reducing mortality from
breast cancer by up to 30% in women aged 50 to 69. The cost-effectiveness of
mammographic screening is influenced by a range of factors. Guidance is that breast
screening programmes should be based within or closely associated with a
recognised Breast Unit, which is already the case in North Wales.
Women with a first degree relative with breast cancer have a three-fold increased
risk of developing the disease. These women should be provided services according
to NICE guidance, which WAG has recently endorsed.
Consensus supports a triple assessment approach in the assessment of
symptomatic women, which all Trusts serving North Wales residents provide.
The role of MRI is under evaluation, although it has an established place in the
investigation of implant dysfunction, recurrent or multifocal malignancy. NICE has
recommended that women at increased risk of breast cancer as a result of their
family history be offered annual MRI scanning. MRI is available on-site at all Units
except for Llandudno Hospital.
Recent draft NICE guidelines suggest that patients with early invasive breast cancer
should be offered DXA scanning in certain circumstances. The DXA scanner for
North Wales is based at Llandudno Hospital.
A Breast Unit must advise and where necessary treat women with benign breast
disease. Treatment of DCIS is by mastectomy or breast conservation therapy. Two
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equally efficacious treatments for Stage 1 and Stage 2 breast cancer are modified
radical mastectomy or breast conservation therapy, followed by radiotherapy.
Pathological staging should be done to direct decisions on adjuvant therapy. Sentinel
Lymph Node Biopsy with pre-operative lymphoscintogram is a safe and effective
alternative to axillary dissection in trained hands. It is provided at all Breast Centres
except for Llandudno Hospital and Countess of Chester (which has plans to
introduce in 2009).
Evidence indicates that immediate breast reconstruction does not adversely affect
breast cancer outcome and has economic benefits, produces better results than
delayed reconstruction and reduces the psychological morbidity associated with
mastectomy. Guidance is that breast reconstruction should be offered to women at
the initial surgical operation and that an oncoplastic breast service should normally
be on site and constitute a core component of the MDT. This does not occur
throughout the current service provided to North Wales residents.
Routine follow up of women with treated breast cancer should be by routine physical
examination and yearly mammography; recent draft NICE guidelines have
suggested yearly mammography until age 70. A specialist palliative service should
be available for referral of cases of breast cancer.
Up to one third of women with breast cancer will suffer from psychological morbidity.
Psychological support should be available at every stage to help patients and their
families cope with the effects of the disease and a breast care nurse should be
available for support and counselling.
At every stage of the patient journey, individuals should be offered clear, objective,
full and prompt information in both verbal and written form and members of the
breast team should have special training in communication and counselling skills.
Local networks and voluntary organisations need to be engaged in this process.
6.4 Organisation of Breast Care Services
Guidance recommends that MDT meetings are held by the Breast Unit at least
weekly, which occurs in North Wales.
Recommendations exist around appropriate staffing of breast units. Each breast Unit
should have at least two consultant surgeons specially trained in breast disease, for
example, which is the case in North Wales.
The evidence base in relation to rural and remote communities shows that there is a
decline in access to services with increasing distance from medical care, and poorer
health outcomes of remove rural residents. There is little direct evidence around the
geographical location of breast units.
Breast Units should have appropriate facilities for diagnosis, treatment and follow-up.
There should be rapid access facilities for bone scanning and other imaging,
including MRI. Attention to be paid to patient privacy, with single sex wards or bays.
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Specialist and hospital caseload and/or specialisation have been shown to be
associated with improved cancer survival. It is recommended that Breast Units
should see at least 100-150 new case of breast cancer per annum and breast
surgeons should see at least 30-50 new cases of breast cancer per annum, and no
more than 150. These recommendations are likely to be fulfilled by the current
service.
Each primary care team should have at least one practitioner who has had specific
training in breast examination. There should be rapid referral of patients from primary
care to a Breast Unit.
Studies have shown benefits of one-stop clinics for breast cancer, although new
technology is making it difficult for patients to be fully assessed in one visit. Patients
should be fully assessed in three visits or less. It is our understanding that North
Wales patients currently have access to one-stop clinics at all Units.
There is good evidence that ambulatory breast surgery can be both safe and
effective, but it is not currently provided in North Wales.
There should be continuity of care and care pathways and referral guidelines should
be used in breast care services.
6.5 Summary of Service Gaps Identified
Comparing the service provided to North Wales residents with evidence and
guidance, it can be seen that the service provided is generally of high quality. All
Trusts are broadly compliant with the national breast cancer standards, EUSOMA
guidelines, NICE Improving Outcomes in Breast Cancer 2002, and BASO
Guidelines.
No hospital, particularly Llandudno Hospital, currently provides all the elements of a
modern breast care service. A particular gap for all Trusts is access to an on-site
comprehensive reconstructive/oncoplastic service. In addition, access to MRI is not
available at Llandudno Hospital (which does, however, have DXA scanning
available). Sentinel Node Biopsy service with Lymphoscintogram is not currently
available in Llandudno Hospital and Countess of Chester (although the latter plans to
introduce this in 2009). HDU/ITU services are currently provided only at the three
main acute hospital sites across North Wales.
6.6 Options for a new service model
Options for a new service model for breast care services need to consider the main
types of breast unit described and recommended activity levels. A range of options
involving the use of up to four Specialist Breast Units and three Diagnostic Breast
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Assessment Units for the North Wales population are provided, based on a series of
assumptions. It should be noted that these options are not comprehensive and there
are other ways in which breast care services could be organised e.g. by performing
diagnosis and routine surgery in one unit, but more complicated surgery in another.
7.0 Recommendations
Recommendations given are as follows:
1/ A detailed option appraisal for delivery of breast care services is undertaken
based on the findings of this rapid review. This should have regard to appropriate
criteria (including the specific needs of a national breast screening programme
delivered by Breast Test Wales) and wider consideration of the provision of general
health care services across North Wales.
2/ As part of this process existing gaps in service provision should be considered
including:
a) further development of a breast reconstruction/oncoplastic service
based in North Wales.
b) introduction of ambulatory breast surgery for North Wales residents.
3) The North Wales health community, with its partners, should seek to:
a) maximise the appropriate uptake of breast screening services
b) actively promote the prevention of disease by working in collaboration to
address lifestyle/ risk behaviour, promote health and tackle inequalities in
health in the North Wales population.
8.0 Acknowledgements
Dinah Roberts and Sian King (NPHS LKMS Team), Martin Heaven and Nathan
Lester (NPHS HIAT Team), Peter Stevenson, Hugo van Woerden (HCW), Iain
Robbé (Cardiff University) Ceri White (WCISU), Damian Heron and Grace LewisParry (North Wales Cancer Network), Rose Fox (BTW) and staff from all the Trusts
for supplying data. In addition, Lynne Chadburn for sorting out tables.
Author: Dr Rob Atenstaedt,
Dr Julia Williams, Mr Andrew Jones
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161. Porta M, Gallen M, Malats. Influence of ‘diagnostic delay’ upon cancer survival: an
analysis of five tumour sites. J Epidemiol Community Health 1991; 45 (3): 225-30.
162. Jones RVH, Dungeon TA. Time between presentation and treatment of six common
cancers: a study in Devon.Br J Gen Pract 1992; 42: 419-22.
163. Gui GP, Allum WH, Perry NM et al. Clinical audit of a specialist symptomatic breast clinic J
R Soc Med 1995; 88: 330-3.
164. Kalbassi MR et al. Symptomatic breast clinic: an efficient resource. Breast J 2006 12(1):
93-4.
165. Lowe JB, Balanda KP, Del Mar, Hawes E. Psychologic distress in women with abnormal
findings in mass mammography screening. Cancer 1999; 85:1114-8.
166. Harcourt D, Ambler N, Rumsey N et al.Evaluation of a one-stop breast lump clinic: a
randomised controlled trial. Breast 1998 7(6): 314-9.
167. Dey P, Blundred N, Gibbs A et al. Costs and benefits of a one stop clinic compared with a
dedicated breast clinic: randomised controlled trial. BMJ 2002: 324(7336): 507.
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168. Athey N, Gilliam AD, Sinha P et al. Day-case breast cancer axillary surgery. Ann R Coll
Surg Engl 2005; 87: 96-8.
169. Gupta R, Pate K, Varshney S et al. A comparison of 5-day and 8-day surgical drainage
following mastectomy and axillary clearance. Eur J Surg Oncol 2001; 27: 26-30.
170. Marchal F, Dravet F, Classe JM et al. Post-operative care and patient satisfaction after
ambulatory surgery for breast cancer patients. Eur J Surg Oncol 2005; 31: 495-499.
171. De Lathower C, Poullier JP. How much ambulatory surgery in the world in 1996-1997 and
trends? Ambulatory Surgery 2000; 8: 191-210.
172. Vuilleumer H, Halkic N. Laparoscopic cholecystecomy as a day case procedure:
implementation and audit of 136 consecutive cases in a university hospital. World J Surg
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173. Warren JL, Riley GF, Potosky AL et al. Trends and outcomes of outpatient mastectomy in
elderly women. J Natl Cancer Instit 90(11): 833-40.
174. Frotscher CAN, Beets GL, von Meyendeldt MF. Breast cancer surgery in a day case
setting: where do the Netherlands stand in 2004? Ambulatory Surgery 2005; 12(2): 61-5.
175. Dooley WC. Ambulatory mastectomy. Am J Surg 2002; 184: 545-9.
176. Tan, LR, Guenther JM. Outpatient definitive breast cancer surgery. Am Surg 1997; 63(10):
865-7.
177. Margolese RG, Lasry JC. Ambulatory surgery for breast cancer patients. Ann Surg Oncol
2000; 7(3): 181-7.
178. Carcano G. et al. Breast cancer surgery as an outpatient in Italy: Is it possible? Chirugia
(Bucur) 2005; 18(5): 323-5.
179. Evans WK, Will BK, Betholet J-M, Logan DM, Mirsky DJ, Kelly N. Breast Cancer: Better
Care for Less Cost. International Journal of Technology Assessment in Health Care; 16:
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180. Bian J, Krontiras H, Allison J. Outpatient mastectomy and breast reconstructive surgery.
Ann Surg Oncol 2008; 15(4): 1032-9.
181. Boman L, Bjorvell H, Languis A et al. Two models of care as evaluated by a group of
women operated on for breast cancer with regard to their perceived well-being. European
Journal of Cancer Care 1999; 8: 87-96
182. Campbell H, Hotchkiss R, Bradshaw N etal. Integrated care pathways BMJ 1998; 316:1337.
183. Grimshaw JM, Russell IT. Achieving health gain through clinical guidelines: developing
scientifically valid guidelines. Quality in Health Care 1993; 3: 45-52.
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Health Care 1999; 5(1):1-16.
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Appendix 1: North Wales Cancer Network: Identification of a model for breast
care services in North Wales.
Introduction
On the 20th March 2008 the Minister wrote to the Chair of Conwy LHB and asked him
to take forward a number of recommendations made about the future of Llandudno
Hospital and also stated that ‘the current breast care service should remain at
Llandudno for the foreseeable future whilst further work and advice is provided on a
model of breast care services in North Wales’.
The purpose of this paper is to set out the process for developing an agreed model
for breast care services for North Wales and the consequent implications for
Llandudno Hospital. The final report needs to be completed in advance of the
development of the service model for Llandudno Hospital being undertaken by
December 2008.
Parameters
In outlining a model of breast services a number of suggested parameters should be
identified at the outset,
 NICE Guidance (Improving Outcomes Guidance in Breast Cancer)
 Compliance with EUSOMA guidelines 2004
 Inclusion of all elements of the breast care pathway
 Recognition of best current and future evidence based best practice
 Inclusion at all stages of all stakeholders including user representation
 Recognition of organisational change in North Wales
Methodology
It is recommended that a three phase approach is taken with associated timescales
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Phase 1
Description
Prepare outline paper
identifying current
workload and anticipated
need for breast care
services, current
services, clinical pathway
and potential issues that
require analysis
Phase 2a
Develop earlier paper to
describe model of service
in line with the agreed
parameters and evidence
based best clinical
practice
Phase 2b
Share outcome of phase
1 and 2a with key
stakeholders, in
particular, Conwy CHC
and the Llandudno
Hospital Action Group.
Phase 3
Recognising the content
of the agreed model
prepare a paper that
provides options for the
service at Llandudno
which will include the
potential financial
implications of the
options identified.
Rapid Review of Breast Care Services in North Wales
By Whom
Public health
Cancer Network officers/ Network
Board
By when
August 08
Public health working with cancer
network team in liaison with
Breast DON which includes
patient and public
representatives. Members of
Conwy CHC will also attend this
event.
End of
September 08
Chair & Director of the Cancer
Network supported by public
health staff.
October 08
Cancer network supported by
input from NHS finance and
service planners and Public
Health.
Nov 08
Reporting
The paper that describes a model for breast services in North Wales and the options
for the service in Llandudno will be reported to Conwy LHB and the Llandudno
Hospital Project Board who will then refer the paper to the North Wales Health
Planning Forum initially before further consultation on the findings takes place.
Accountability
Accountability for the production of this work rests with Conwy LHB and the Network
officers and the stakeholder staff will be contributing to this piece of work on behalf of
the LHB.
Author: Dr Rob Atenstaedt,
Dr Julia Williams, Mr Andrew Jones
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Appendix 2: Estimated Population Projections for North Wales 2003 - 2028
Year
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
All ages
670.8
675
678.3
680.5
681.6
682.7
683.8
684.9
686
687
688.1
689
690
690.9
691.7
692.5
693.2
693.8
694.4
694.7
695
695
695
694.7
694.3
693.7
Aged 0 to 4
36.2
35.9
35.7
35.4
35.4
35.4
35.1
34.7
34.5
34.2
34.1
33.9
33.8
33.7
33.5
33.4
33.3
33.2
33
32.8
32.6
32.4
32.1
31.9
31.6
31.3
Aged 5 to 9
Aged 10 to
14
Aged 15 to
19
Aged 20 to
24
Aged 25 to
29
Aged 30 to
34
Aged 35 to
39
Aged 40 to
44
Aged 45 to
49
Aged 50 to
54
Aged 55 to
59
Aged 60 to
64
Aged 65 to
69
Aged 70 to
74
Aged 75 to
79
Aged 80 to
84
40.2
40.1
39.9
39.6
38.6
37.8
37.4
37
36.6
36.7
36.6
36.3
36
35.7
35.5
35.3
35.2
35.1
34.9
34.8
34.7
34.6
34.4
34.3
34.1
33.9
43.7
43.5
43.2
42.6
42
41.6
41.3
41
40.6
39.7
38.9
38.4
38
37.7
37.7
37.7
37.4
37
36.8
36.6
36.4
36.2
36.1
36
35.9
35.8
42
42.6
42.5
43
43.2
43.2
42.8
42.4
41.8
41.2
40.8
40.5
40.2
39.8
38.9
38.1
37.6
37.3
36.9
37
36.9
36.6
36.3
36
35.8
35.7
36.5
37.1
37.7
37.6
38.2
38.7
38.8
38.3
38.7
39
38.9
38.6
38.2
37.5
37
36.6
36.3
36
35.6
34.7
33.9
33.5
33.1
32.8
32.8
32.8
34
34.4
35.3
36.2
36.2
36.4
36.6
36.9
36.7
37.3
37.8
38
37.5
37.9
38.1
38
37.7
37.3
36.7
36.1
35.7
35.4
35.1
34.7
33.8
33
43.9
42.3
40.6
38.3
36.6
35.4
35.4
36.1
36.9
36.9
37.2
37.4
37.7
37.5
38.1
38.6
38.8
38.3
38.7
38.9
38.8
38.5
38.1
37.5
36.9
36.5
47.6
47.3
46.9
46.9
46.5
45.6
43.8
41.9
39.6
37.9
36.7
36.7
37.4
38.2
38.2
38.5
38.7
39
38.8
39.4
39.9
40.1
39.7
40
40.2
40.2
46.3
47.9
49
49.6
49.6
49.2
48.7
48.2
48.1
47.7
46.8
45
43.2
40.9
39.2
38
38
38.7
39.5
39.5
39.8
40
40.3
40.2
40.7
41.2
42.6
43
43.9
44.8
45.8
47.2
48.6
49.6
50.1
50.2
49.7
49.2
48.8
48.7
48.3
47.4
45.6
43.8
41.5
39.8
38.6
38.7
39.4
40.2
40.2
40.5
45.3
44.5
43.8
43.5
43.7
43.7
43.9
44.7
45.7
46.7
48
49.4
50.4
50.9
50.9
50.5
50.1
49.6
49.5
49.2
48.3
46.5
44.7
42.5
40.8
39.7
48.5
49.8
50.4
50.4
48.2
46.6
45.7
44.9
44.6
44.8
44.9
45.1
45.9
46.8
47.8
49.1
50.4
51.5
52
52
51.6
51.2
50.8
50.7
50.3
49.5
39.4
40.9
42.4
43.9
46.9
48.9
49.9
50.5
50.5
48.4
46.9
46.1
45.3
45
45.2
45.3
45.6
46.4
47.2
48.2
49.5
50.8
51.9
52.4
52.4
52
34.5
35.4
36.2
36.8
37.5
38.7
40
41.4
42.8
45.7
47.6
48.6
49.2
49.2
47.3
45.9
45.1
44.4
44.2
44.4
44.5
44.8
45.6
46.4
47.4
48.6
30
29.8
29.9
30.3
31
31.8
32.7
33.4
34
34.7
35.9
37.2
38.5
39.8
42.6
44.3
45.3
45.8
45.9
44.1
42.9
42.2
41.6
41.4
41.7
41.8
25.3
25.5
25.5
25.6
25.5
25.5
25.5
25.7
26.1
26.8
27.7
28.6
29.3
29.9
30.6
31.7
32.8
34
35.2
37.7
39.4
40.3
40.7
40.8
39.3
38.3
19.3
19.6
19.5
19.3
19.2
19.2
19.4
19.6
19.7
19.8
19.9
20
20.3
20.8
21.5
22.3
23.1
23.8
24.4
25
26
27
28
29.1
31.2
32.6
15.3
15.4
16.1
16.7
17.4
17.8
18.1
18.5
18.9
19.3
19.7
20.1
20.5
20.9
21.4
21.8
22.2
22.8
23.5
24.4
25.3
26.2
27.1
28
29
30.3
AGEGROUP
Aged 85 &
over
Author: Dr Rob Atenstaedt,
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Appendix 3: Methodology for calculating Breast Cancer Projections (36)
Data for all cancer cases for the period 1976-2005 for those subjects aged 30 or
over at diagnosis for female breast cancer in North Wales were extracted from the
database held at the Welsh Cancer Intelligence & Surveillance Unit, Cardiff
(WCISU). The cases were all linked to equivalent population data also obtained
through ONS.
2005 based population projections were acquired from the
Government Actuary’s Department website (http://www.gad.gov.uk) to facilitate
projection of incidence into the future whilst adjusting for the predicted change in the
structure of the Welsh population. Numbers of cases have been tabulated in 5 year
time periods, the first time period being 1976-1980 with five year groupings up to the
latest time period 2001-2005.
The data was modelled using age-period-cohort (APC) analysis in the form proposed
by Clayton and Schifflers 1,2 using the statistical package STATA (StataCorp LP,
Stata 9.1 for Windows., College Station Texas, USA, http://www.stata.com). The
APC analysis fits regression models to the data and describes the incidence rate as
a function of age, calendar period and birth cohort. Following the selection of the
‘best’ model, this model is used to project future trends. Since the age, calendar
period and birth cohort are inherently linked (linearly dependent) the modelling is
unable to distinguish between the linear effects of time period and of birth cohort.
Consequently the model is parameterised to include a drift parameter, which
describes the linear trend not attributable to either period or cohort effects.
Models were considered sequentially with the addition of further terms, and
compared with the previous model using a likelihood ratio test. To allow for multiple
testing the more complex model has only been accepted if p<0.01 as opposed to the
conventional cut-off value of p<0.05. The null model was that containing just age.
The terms added sequentially were then drift (D), non-linear period (P) or non-linear
cohort (C), non-linear period and non-linear cohort (PC), the most complex model
being the full APC model with drift (APCD). If both non-linear calendar period and
non-linear birth cohort, individually, met the criteria for inclusion then the one
selected was that with the highest statistical significance.
The ‘best’ model was used to project future incidence for the calendar periods 20062010, 2011-2015 and 2016-2020. In order to do this it is crucial to include
appropriate values for the effects of age and, if required by the model, of calendar
period and birth cohort. The age effects from the ‘best’ model have simply been
carried into the future models.
Since we are predicting into the future we of course have no information about the
effects of the future calendar periods. For our analysis it has been assumed that the
effects of time period for these three periods are the same as that of the most recent
time period included in the analysis, 2001-2005.
1
Clayton D, Schliffers E. Models for temporal variations in cancer rates I. Age-period and age-cohort
models. Stat Med 1987; 6: 449-467
2
Clayton D, Schliffers E. Models for temporal variations in cancer rates II. Age-period-cohort models.
Stat Med 1987; 6: 469-481
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These future calendar time periods also incorporate birth cohorts which have not
been included in the modelling process and for which we therefore have no
information. It seems logical to assume that the situation for these birth cohorts will
be nearest that of the youngest birth cohort included in the analysis (those aged 3034 in 2001-2005). However, due to small numbers of cases in this cohort, future
birth cohorts are assumed to be the same as those aged 30-44 in 2001-2005.
The drift represents a linear trend by calendar period or birth cohort. It is not
possible to say whether the inclusion of this term is valid for future projections; as
such we have considered predictions both with and without. The choice over the
inclusion or exclusion of the drift term has been influenced by its statistical
significance in the model and by examination of the predicted values with the
historical data.
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Appendix 4: Maps of breast screening uptake for individual LHBs
Breast screening uptake, round 5, Anglesey LHB, split by ward
Author: Dr Rob Atenstaedt,
Dr Julia Williams, Mr Andrew Jones
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Breast screening uptake, round 5, Gwynedd LHB, split by ward
Author: Dr Rob Atenstaedt,
Dr Julia Williams, Mr Andrew Jones
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Breast screening uptake, round 5, Conwy LHB, split by ward
Author: Dr Rob Atenstaedt,
Dr Julia Wiliams, Mr Andrew Jones
Version: 5
Date: 5/12/08
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Breast screening uptake, round 5, Denbighshire LHB, split by ward
Author: Dr Rob Atenstaedt,
Dr Julia Wiliams, Mr Andrew Jones
Version: 5
Date: 5/12/08
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Breast screening uptake, round 4, Flintshire LHB, split by ward
Author: Dr Rob Atenstaedt,
Dr Julia Wiliams, Mr Andrew Jones
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Breast screening uptake, round 5, Wrexham LHB, split by ward
Author: Dr Rob Atenstaedt,
Dr Julia Wiliams, Mr Andrew Jones
Version: 5
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Appendix 5: Service Activity
Table 22: Volumes (2006)
YGC
BTW
50
2230
46
1087
45
52
1629
CoCH
Figs are approx as
database incomplete.
They refer to all pts
(including English pts)
unless specifically
stated
48
1904
124
17
196
55
57
1037
1659*
4383
97
162
171 (25 from Wales)
YG
Number of MDT meetings held
Number of new symptomatic referrals
Number of Screen Detected Cancers
diagnosed
Number of Follow up appoints
(*this figure is an underestimation and
does not include those breast patients
attending general surgical clinics or
those attending for seroma or
abscess drainage, ward referrals or
‘drop ins;)
Number of New Symptomatic Breast
Cancers diagnosed
Author: Dr Rob Atenstaedt,
Dr Julia Williams, Mr Andrew Jones
Version: 5
LLandudno
1845
Date: 5/12/08
Page 111 of 132
1635
195
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Wrexham
Maelor
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Rapid Review of Breast Care Services in North Wales
Staffing Complement and Vacancies
NB- Not aware of any vacancies as at 2.8.08 for all Trusts
Table 23: Core Team Members
Number of named core team members
YG
Llandudno
YGC
BTW
Wrexham Maelor
Core team members spending ≥ 50% direct clinical care time on breast cancer
work
YG
Llandudno
Glan Clwyd
BTW
Wrexham Maelor
Core team members attending ≥ 50%of MDT meetings
YG
Llandudno
Glan Clwyd
BTW
Wrexham Maelor
Author: Dr Rob Atenstaedt,
Dr Julia Williams, Mr Andrew Jones
Version: 5
Date: 5/12/08
Page 112 of 132
Surgeons
Radiologists
Pathologists
Oncologists
2
2
5
2
3
2
3
2
3
1
0.3
1+
2
1+
0
1+
Surgeons
Radiologists
Pathologists
Oncologists
2/2
2/2
5/5
2/2
2/3
0/2
3/3
?
0/3
0/2
0/3
?
2/2
¾
0
0
Surgeons
Radiologists
Pathologists
Oncologists
2/2
2/2
3/5
2/2
2/3
2/2
3/3
1/2
2/3
1/2
1/3
2/2
2/2
2/4
0
1/1
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NHS Wales (Intranet)
Nurse
Specialists
2.8
2
2
1.5
Nurse
Specialists
2.8/2.8
3/3
2/2
2/2
Nurse
Specialists
1/2.8
2/3
2/2
2/2
National Public Health Service for Wales
Rapid Review of Breast Care Services in North Wales
Table 24: Extended Team Members
Palliative
Care
YG
Llandudno
YGC
BTW
Wrexham
Maelor
Radiographer
Psychiatrist
or Clinical
Social
Psychologist Worker
Plastic or
Clinical
Physio or
Reconstructive Geneticist/Geneticist Lymphoedema
Surgeon
Counsellor
specialist


X





X


X


X


X


X







Others
Extended team members regularly attending MDT
Palliative
Care
YG
Llandudno
YGC
BTW
Wrexham
Maelor
Radiographer
Psychiatrist
or Clinical
Social
Psychologist Worker
Plastic or
Clinical
Reconstructive Geneticist/Geneticist Physio/Lymphoedema
Surgeon
Counsellor
specialist
Others
x

N/A

x
x
x
x
N/A
x
x
N/A
x
x
N/A
x
x
N/A
x
x
N/A
x

x
x
x
x
x
Author: Dr Rob Atenstaedt,
Dr Julia Williams, Mr Andrew Jones
Version: 5
Date: 5/12/08
Page 113 of 132
Status: Approved
Intended Audience: Public (Internet) /
NHS Wales (Intranet)


National Public Health Service for Wales
Rapid Review of Breast Care Services in North Wales
Table 25 – Treatment (2006 data)
Wrexham
Maelor
Llandudno
YG
YGC
Whiston
BTW
C of Chester
NB Reconstruction figures
apply only to breast
service, not plastics
9. This number refers to
Breast biopsies (Open / closed)
539
304
-
445
Wide local excisions
106
68
49
-
-
87
72
42
11
-
9
0
0
12
-
0
7
-
Mastectomies
Primary reconstructions – implant
Primary reconstructions - myocutaneous flap
Secondary reconstructions – implant
Secondary reconstructions - myocutaneous
flap
Endocrine therapy
6
0
0
2
-
0
0
0
-
-
20
15
-
-
6
12
-
-
Neo-adjuvant chemo
Axillary clearances
73
52
91
1
-
66
107
0
44
1
-
Axillary samples – (level 1?)
Sentinel node biopsies
Author: Dr Rob Atenstaedt,
Dr Julia Williams, Mr Andrew Jones
Version: 5
51
Date: 5/12/08
Page 114 of 132
Status: Approved
Intended Audience: Public (Internet) /
NHS Wales (Intranet)
359
104
purely diagnostic
procedures and not
excisions at pt requests.
71
75
81
0
33
0
6
0
2
0
9
23
19
2
6
56
100
98
34
84 (2007)
4
National Public Health Service for Wales
Rapid Review of Breast Care Services in North Wales
Table 26 - Pathology
YG
C
L
A
Llandudno
C
L
A
YGC
D
A
New Appt Aug 07
Wrexham Maelor
Do
B
P
B
CoCH
SH
BH
JE
NM
Author: Dr Rob Atenstaedt,
Dr Julia Williams, Mr Andrew Jones
Version: 5
Cytology/Pathology
Participate in National EQA
Qualifications consistent with BSP QA
Guidelines
P
P
P
Y
Y
Y
Y
Y
Y
C
C
C
Y
Y
Y
Y
P&C
P&C
P&C
N
N
N
N
P&C
P&C
P&C
P&C
Y
Y
Y
Y
Y
N
Y
N
C&P
C&P
C&P
C&P
Y
Y
Y
Y
Y
Y
Y
Y
Date: 5/12/08
Page 115 of 132
Status: Approved
Intended Audience: Public (Internet) /
NHS Wales (Intranet)
Y
National Public Health Service for Wales
Rapid Review of Breast Care Services in North Wales
Table 27 – Imaging
Participate in Breast
Screening
Programme
Qualifications
consistent with BSP
QA
Symptomatic
Mammograms
Screening
mammograms
MDTs attended
Diagnostic clinics
attended
Y
N
Y
Y
Y
Y
1411
1410
0
10391
0
6929
43
37
0
41
41
0
N
Y (s)
Y (s)
716
578
0
0
37
36
38
10
Y
Y
Y
Y
Y
Y
Y
Y
10391
6929
7289
5786
39
38
37
21
Y
Y
Y
Y
1492
5200
50
?
?
?
?
?
?
?
?
?
?
NWWT
G
B
E
YGC
MC
W
BTW
G
E
B
SH(ret)
Wrexham
Maelor
Pa
Po
CoCH
Pi
K
H
Y
Author: Dr Rob Atenstaedt,
Dr Julia Williams, Mr Andrew Jones
Version: 5
Y
Date: 5/12/08
Page 116 of 132
Y
3189
Status: Approved
Intended Audience: Public (Internet) /
NHS Wales (Intranet)
~40
Approximately 35
clinics pa. Mrs Kelly
attends twice weekly
and thus does 70
clinics pa
National Public Health Service for Wales
Rapid Review of Breast Care Services in North Wales
Table 28 – Reading
Screening
Single Reading
NWWT
YGC
BTW
Symptomatic
Double Reading
Y
N
Y
Single Reading
Double Reading
N
Y
Wrexham Maelor
CoCH
USS
N
Y
Y
N
Y
Y
Y
Cons Radiologist
Cons Radiologist
Cons Radiologist/
Breast Clinician
Con Radiologist/ Breast
Clinician
Cons radiologist
Cons radiographer
Table 29 – Sentinel Lymph Node Biopsy
Gamma Probes
Y
N
Y
Y
Y
Attended Theory Day
Y
Y
Nuclear Medicine on
site
Y
N
Y
Y
Y
Booked Theory Day
Y
Y
Waste facilities
Y
N
Y
Y
Y
Proctored Cases
Y
Y
YGC
Y
Y
Y
Y
Wrexham Maelor
Y
Y
Y
Y
YG
Llandudno
YGC
Wrexham Maelor
CoCH
Ysbyty Gwynedd
Llandudno
Author: Dr Rob Atenstaedt,
Dr Julia Williams, Mr Andrew Jones
Version: 5
Date: 5/12/08
Page 117 of 132
Status: Approved
Intended Audience: Public (Internet) /
NHS Wales (Intranet)
ARSAC holder
Dr Gash
Archard/McConnell
Parker
Pilbrow
Audit Phase
Y
Y
Lymphoscintogram
Y
N
Y
Y
Y
SNB Cases
51
44
2006-40
2007 - 104
National Public Health Service for Wales
CoCH
Author: Dr Rob Atenstaedt,
Dr Julia Williams, Mr Andrew Jones
Version: 5
Rapid Review of Breast Care Services in North Wales
Y
Y
Date: 5/12/08
Page 118 of 132
Y
Status: Approved
Intended Audience: Public (Internet) /
NHS Wales (Intranet)
Y
70 as of Sept 08.
National Public Health Service for Wales
Rapid Review of Breast Care Services in North Wales
Appendix 6: Search Strategies for Literature Review
Title of Search : Breast care service review
For : Dr Rob Atenstaedt
Conwy & Denbighshire
By: Dinah Roberts/Sian King
LKMS, Swansea
Date : 25 July 2008
Updated:
1. Search Strategy.
Search Questions:
o
o
What is the epidemiology of breast disease (breast cancer and benign breast
conditions) ?
What are the elements of a high quality breast care services?
o Screening [ refer Breast Screening Wales standards]
o diagnostic/treatment/
o surgical service?
o Comparative
What breast care models are currently in operation in the UK/ Europe/ Developed
World?
Key Words -thesaurus/free text/MeSH
Epidemiology:
Statistical data
Medical statistical data
Epidemiology
“Prevalence of disease”
“Incidence of disease”
Breast cancer
Breast neoplasm
United Kingdom
Services:
Breast care service$
Breast cancer service$
Breast clinic$
Breast cancer clinics(HMIC)
Breast unit$/Cancer unit$
Cancer diagnostic centres (HMIC)
Breast neoplasms
Cancer care facilities **
Cancer center
Cancer centres (HMIC)
Cancer services (HMIC)
Cancer hospitals (HMIC)
Cancer model
Service provision
Health care delivery
Health care quality
Health care access
Health care organization
Patient care
Health care management
Health care facility
Health care system
Hospital service
Author: Dr Rob Atenstaedt,
Dr Julia Williams, Mr Andrew Jones
Version: 5
Date: 5/12/08
Page 119 of 132
Status: Approved
Intended Audience: Public (Internet)
/ NHS Wales (Intranet)
National Public Health Service for Wales
Rapid Review of Breast Care Services in North Wales
Health service
Oncology services, Hospital
Oncologic care
Oncologic nursing
Breast diseases
Breast neoplasms
Breast cancer
Breast
All
Publication types –guidelines,
systematic reviews, press releases
conference proceedings, published
statistics etc
Limitations
 Language
English language
 Dates covered
1996 Non UK
Yes
 Other limitations/exclusions
** - this term used in conjunction with breast cancer/neoplasms/disease brought the
most appropriate set of results.
Title of Search : Breast disease
For : Dr R Atenstaedt
Conwy & Denbighshire LPHD
By: Sian King
LKMS Swansea
Date : 05/08/08
Updated:
1. Search Strategy.
Search Question: To locate general review papers on aetiology, prevention and
management of breast diseases. (to supplement search on breast care services
review.)
Key Words -thesaurus/free text/MeSH
Breast diseases[Etiology, Prevention,
Nursing, surgery, Diagnosis, Disease
Management, Epidemiology]
Breast abnormalities
Breast neoplasms
Breast cancer
Breast$
preventive medicine
clinical examination detection
diagnosis
disease management
Publication types –guidelines,
systematic reviews, press
releases,conference proceedings,
published statistics etc
Limitations
 Language
 Dates covered
 Non UK
 Other limitations/exclusions
Guidelines, reviews, review articles
Author: Dr Rob Atenstaedt,
Dr Julia Williams, Mr Andrew Jones
Version: 5
English
1994Yes
Date: 5/12/08
Page 120 of 132
Status: Approved
Intended Audience: Public (Internet)
/ NHS Wales (Intranet)
National Public Health Service for Wales
Rapid Review of Breast Care Services in North Wales
Title of Search : Breast cancer surgery
For : Dr Rob Atenstaedt
Conwy & Denbighshire
By: Sian King
LKMS Swansea
Date : 12/08/08
Updated:
1. Search Strategy.
Search Questions:
Is there any evidence that surgery for breast cancer can be done as a day case
procedure?
Key Words -thesaurus/free text/MeSH
Breast cancer
Breast neoplasms
Breast tumor,
Breast carcinoma
Day surgery
Day case surgery
Ambulatory surgical procedures
Ambulatory Surgery,
Publication types –guidelines,
systematic reviews, press releases
conference proceedings, published
statistics etc
Limitations
 Language
 Dates covered
 Non UK
 Other limitations/exclusions
All
English language
1996Yes
Title of Search : Organisation of breast cancer services
For : Dr R Atenstaedt
Conwy & Denbighshire LPHT
By: Sian King
LKMS Swansea
Date : 21/08/08
Updated:
1. Search Strategy.
Search Question: Is there any guidance on how the following services should
be organised:
Oncoplastic breast surgery
Localisation biopsy/guide wire breast excision?
Key Words -thesaurus/free text/MeSH
Author: Dr Rob Atenstaedt,
Dr Julia Williams, Mr Andrew Jones
Version: 5
Breast cancer , ab,an,di,su
Breast neoplasms, ab,an,di,su
Breast tumor, ab,an,di,su
Breast lesion, ab,an,di,su
Breast carcinoma, ab,an,di,su
Carcinoma Ductal - breast
Breast abnormalities
Breast-su
Breast biopsy
Biopsy-needle
Stereotactic breast biopsy
Date: 5/12/08
Page 121 of 132
Status: Approved
Intended Audience: Public (Internet)
/ NHS Wales (Intranet)
National Public Health Service for Wales
Publication types –guidelines,
systematic reviews, press releases
conference proceedings, published
statistics etc
Limitations
 Language
 Dates covered
 Non UK
 Other limitations/exclusions
Author: Dr Rob Atenstaedt,
Dr Julia Williams, Mr Andrew Jones
Version: 5
Rapid Review of Breast Care Services in North Wales
Skin-marking
Guide$wire
Wire-localised breast biopsy (WLBB)
Excision biopsy
Clinical examination detection
Surgery, Plastic
Cosmetic surgery
Reconstructive surgical procedures
Breast reconstruction
Service provision
Health care delivery/delivery of health
care
Health care organization
Health care management
Health service accessibility
Quality of health care/quality
improvement/quality assurance
Workforce
Oncology services, Hospital
Oncologic care (units)
Cancer care facilities
Service organi?ation
Guidelines, reviews, reports, review
articles
English
1996=<
Yes
Date: 5/12/08
Page 122 of 132
Status: Approved
Intended Audience: Public (Internet)
/ NHS Wales (Intranet)
National Public Health Service for Wales
Rapid Review of Breast Care Services in North Wales
Appendix 7: Compliance against standards
Table 33: National Breast Cancer Standards. All Trusts are broadly compliant but may have the following exceptions:
YG
Llandudno
YGC
Wrexham Maelor
2.1e The Trust does not
2.1e The Trust does not
2.1e The Trust does not have a
2.1e The Trust does not have a
have a designated Lead
have a designated Lead
designated Lead Cancer Nurse
designated Lead Cancer Nurse as part
Cancer Nurse as part of
Cancer Nurse as part of
as part of their Cancer
of their Cancer Management Team.
their Cancer Management
their Cancer Management
Management Team.
Team.
Team.
4.2 The Trust is working towards 4.2 The Trust is working towards
4.2 The Trust is working
4.2 The Trust is working
ensuring that all relevant
ensuring that all relevant sections of
towards ensuring that all
towards ensuring that all
sections of the All Wales Cancer the All Wales Cancer Data set are
relevant sections of the All
relevant sections of the All
Data set are completed for each completed for each new patient
Wales Cancer Data set are Wales Cancer Data set are
new patient diagnosed with
diagnosed with breast cancer through
completed for each new
completed for each new
breast cancer through the
the development of CANISC.
patient diagnosed with
patient diagnosed with
development of CANISC.
breast cancer through the
breast cancer through the
development of CANISC.
development of CANISC.
6.2 The MDT does not have a
6.2 MDT does not have a
6.2 The MDT does not have ‘written programme of audit to
6.2 The MDT does not have a ‘written
‘written programme of audit a ‘written programme of
assess adherence to clinical
programme of audit to assess
to assess adherence to
audit to assess adherence to policies’, and has neither carried adherence to clinical policies’, and has
clinical policies’, and has
clinical policies’, and has
out an audit confirming
neither carried out an audit confirming
neither carried out an audit neither carried out an audit
adherence to such policies but
adherence to such policies but work is
confirming adherence to
confirming adherence to
work is in hand to address this.
in hand to address this.
such policies but work is in such policies but work is in
hand to address this.
hand to address this.
9.2 The Radiotherapy Centre
9.2 The Radiotherapy
(based at YGC) has not jointly
9.2 The Radiotherapy Centre (based at
Centre (based at YGC) has 9.2 The Radiotherapy
agreed (or otherwise agreed)
not jointly agreed (or
Centre (based at YGC) has
definitions to monitor major long- YGC) has not jointly agreed (or
otherwise agreed)
not jointly agreed (or
term morbidity following radical
otherwise agreed) definitions to monitor
Author: Dr Rob Atenstaedt,
Dr Julia Williams, Mr Andrew Jones
Version: 5
Date: 5/12/08
Page 123 of 132
Status: Approved
Intended Audience: Public (Internet)
/ NHS Wales (Intranet)
CoCH
NB: Not
subject to
Welsh
Standards
National Public Health Service for Wales
definitions to monitor major
long-term morbidity
following radical
radiotherapy.
9.3 The monitoring of major
long-term morbidity rates
following radical
radiotherapy is not carried
out.
10.4 The monitoring of
major morbidity following
chemotherapy in patients
treated with curative intent
is not carried out.
Author: Dr Rob Atenstaedt,
Dr Julia Williams, Mr Andrew Jones
Version: 5
Rapid Review of Breast Care Services in North Wales
otherwise agreed) definitions radiotherapy.
to monitor major long-term
9.3 The monitoring of major
morbidity following radical
radiotherapy.
long-term morbidity rates
following radical radiotherapy is
9.3 The monitoring of major
not carried out.
long-term morbidity rates
10.4 The monitoring of major
following radical
radiotherapy is not carried
morbidity following
out.
chemotherapy in patients treated
with curative intent is not carried
10.4 The monitoring of major out.
morbidity following
chemotherapy in patients
treated with curative intent is
not carried out.
Date: 5/12/08
Page 124 of 132
Status: Approved
Intended Audience: Public (Internet)
/ NHS Wales (Intranet)
major long-term morbidity following
radical radiotherapy.
9.3 The monitoring of major long-term
morbidity rates following radical
radiotherapy is not carried out.
10.4 The monitoring of major morbidity
following chemotherapy in patients
treated with curative intent is not
carried out.
National Public Health Service for Wales
Rapid Review of Breast Care Services in North Wales
Table 34: EUSOMA Guidelines/Recommendations. All Trusts are broadly compliant but may have the following exceptions:
YG
Llandudno
YGC
Wrexham Maelor
CoCH
4.1
Compliant
Compliant
Compliant
Compliant
Compliant
4.2
Compliant
Compliant
Compliant
Compliant
Compliant
4.3
Regular audit meetings
Regular audit meetings
Regular audit meetings
Regular audit meetings
Regular audit meetings
not held
not held
not held
not held
not held
4.4
Compliant
Compliant
Compliant
Compliant
Compliant
4.5
Compliant
Compliant
Compliant
Compliant
Compliant
4.6
Compliant
Compliant
Compliant
Compliant
Compliant
4.7
Compliant
Compliant
Compliant
Compliant
Compliant
4.8
Compliant
Compliant
Compliant
Compliant
Compliant
4.9
Compliant ( - recon)
Compliant( - recon)
Compliant( - recon)
Compliant( - recon)
Compliant( - recon)
4.10
Not done
Not done
Not done
Not done
Not done
5.1
Compliant
Compliant
Compliant
Compliant
Compliant
5.2
Compliant
Compliant
Compliant
Compliant
Compliant
5.2.1
Not the case in N Wales
Not the case in N Wales
Not the case in N Wales
Not the case in N Wales
Not the case in N Wales
5.2.2
Major deficits exist
Major deficits exist
Major deficits exist
Major deficits exist
Compliant
regarding reconstruction
regarding reconstruction
regarding reconstruction
regarding reconstruction
5.2.3
Compliant
Compliant
Data for 2007 non
Compliant
Compliant?
compliance
5.2.4
Compliant
Compliant
Compliant
Compliant
Compliant
5.2.5
Compliant
Compliant
Compliant
Compliant
Compliant
5.2.6
Compliant
Compliant
Compliant
Compliant
Compliant
5.2.7
Compliant
Compliant
Compliant
Compliant
Compliant
5.2.8
Compliant
Compliant
Compliant
Compliant
Compliant
6.1
Compliant
Compliant
Compliant
Compliant
Compliant
6.2
No local brachytherapy
No local brachytherapy
No local brachytherapy
No local brachytherapy
No local brachytherapy
available
available
available
available
available
7.1
Compliant
Compliant
Compliant
Compliant
Compliant
7.2
Compliant
Compliant
Compliant
Compliant
Compliant
7.3
Compliant
Compliant
Compliant
Compliant
Compliant
Author: Dr Rob Atenstaedt,
Dr Julia Williams, Mr Andrew Jones
Version: 5
Date: 5/12/08
Page 125 of 132
Status: Approved
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/ NHS Wales (Intranet)
National Public Health Service for Wales
7.4
7.5
7.6
7.7
7.8
7.9
7.10
7.11
7.12
8.1
8.2
8.3
8.4
8.5
8.6
9
10
11
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
See 8.2
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Author: Dr Rob Atenstaedt,
Dr Julia Williams, Mr Andrew Jones
Version: 5
Rapid Review of Breast Care Services in North Wales
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
See 8.2
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Date: 5/12/08
Page 126 of 132
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
See 8.2
Not universal
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Status: Approved
Intended Audience: Public (Internet)
/ NHS Wales (Intranet)
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
See 8.2
Not universal
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
See 8.2
?
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
National Public Health Service for Wales
Rapid Review of Breast Care Services in North Wales
Table 35: NICE Improving Outcomes in Breast Cancer 2002
YG
Llandudno
1. Primary care and the
Compliant except for Compliant except for
management of women at confirmation that
confirmation that
high risk
each primary care
each primary care
team has a
team has a
practitioner trained in practitioner trained in
clinical breast
clinical breast
examination
examination
2. Patient- centred care
Compliant
Compliant
YGC
Compliant except for
confirmation that
each primary care
team has a
practitioner trained in
clinical breast
examination
Compliant
Wrexham Maelor
Compliant except for
confirmation that
each primary care
team has a
practitioner trained in
clinical breast
examination
Compliant
CoCH
Compliant except for
confirmation that
each primary care
team has a
practitioner trained in
clinical breast
examination
Compliant
3. Rapid and accurate
diagnosis
Compliant
Compliant
Compliant
Compliant
Compliant
4. Surgery
Issues around
access to
reconstruction.
Unknown if
guidelines are
surgical margins
adhered to.
Issues around
access to
reconstruction.
Unknown if
guidelines are
surgical margins
adhered to
Issues around
access to
reconstruction
Unknown if
guidelines are
surgical margins
adhered to.
Issues around
access to
reconstruction.
Unknown if
guidelines are
surgical margins
adhered to
Issues around
access to
reconstruction.
Unknown if
guidelines are
surgical margins
adhered to
5. Radiotherapy
Compliant
Compliant
Compliant
Compliant
Compliant
6. Systemic therapy for
early breast cancer
7. Follow-up after
treatment for early breast
cancer
8. Management of
advanced, recurrent and
metastatic disease
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Author: Dr Rob Atenstaedt,
Dr Julia Williams, Mr Andrew Jones
Version: 5
Date: 5/12/08
Page 127 of 132
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/ NHS Wales (Intranet)
National Public Health Service for Wales
Rapid Review of Breast Care Services in North Wales
9. Palliative care
Compliant
Compliant
Compliant
Compliant
Compliant
10. The breast care team
Compliant
Compliant
Compliant
Compliant
Compliant
11. Inter-professional
communication
12. Clinical guidelines, up
to date practice and CPD
13 Environment and
facilities
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Author: Dr Rob Atenstaedt,
Dr Julia Williams, Mr Andrew Jones
Version: 5
Date: 5/12/08
Page 128 of 132
Status: Approved
Intended Audience: Public (Internet)
/ NHS Wales (Intranet)
National Public Health Service for Wales
Rapid Review of Breast Care Services in North Wales
Table 36: Association of Breast Surgery Guidelines
YG
1. Breast Care Nurse
Compliant
Llandudno
Compliant
YGC
Compliant
Wrexham Maelor
Compliant
CoCH
Compliant
2. Quality Assurance
Compliant
Compliant
Compliant
Compliant
Compliant
3. Multidisciplinary meetings
Compliant
Compliant
Compliant
Compliant
Compliant
4. Breast Clinic
Compliant
Compliant
Compliant
Compliant
Compliant
5. Diagnosis
Compliant
Compliant
Compliant
Compliant
Compliant
6. Management Protocol
Compliant
Compliant
Compliant
Compliant
Compliant
7. Surgery
1st Outcome measure
2nd Outcome measure
Not known
Compliant
Not known
Compliant
Not known
Compliant
Not known
Compliant
Not known
Compliant
8. Local recurrence
Not known
Not known
Not known
Not known
Not known
9. Surgery 2
Not known
Not known
Not known
Not known
Not known
10. Radiotherapy
Compliant
Compliant
Compliant
Compliant
Compliant
11. Training and CPD
1st Outcome measure
2nd Outcome measure
Compliant
Not known
Compliant
Not known
Compliant
Not known
Compliant
Not known
Compliant
Not known
12. Clinical Trials
Compliant
Compliant
Compliant
Compliant
Compliant
Author: Dr Rob Atenstaedt,
Dr Julia Williams, Mr Andrew Jones
Version: 5
Date: 5/12/08
Page 129 of 132
Status: Approved
Intended Audience: Public (Internet)
/ NHS Wales (Intranet)
National Public Health Service for Wales
Rapid Review of Breast Care Services in North Wales
Appendix 8:
Table 37: Mapping of Provision of 5 ‘N Wales Breast Units’ against those expected in a Modern Breast Unit
Features Expected In A Modern Breast
Unit
Diagnosis
YG
Llandudno
YGC
Wrexham Maelor
CocH
Triple assessment clinic
– with mammography, ultrasound and
cytology



???

HER 2 testing on site
X
X
X
X
 Done at Arrowpark with
FISH@RLUH.
Has been audited for
timeliness and CofCh do well.
An integrated symptomatic and screening
service
X
A mammotome biopsy device


X


X
 Access
available
 A vacuum assisted biopsy
system is available & in use
(Vacuflash)
 BTW
Breast magnetic resonance imaging

X

??
??
CT scanning

X

??
??
Cross sectional MRI imaging

X

??
??
Dexa Bone density scanning
X

X
X Access at
Gobowen
X GPs are asked to do these
Stereotactic core biopsy

 BTW

??
??
Active trial recruitment



??
??
Author: Dr Rob Atenstaedt,
Dr Julia Williams, Mr Andrew Jones
Version: 5
Date: 5/12/08
Page 130 of 132
Status: Approved
Intended Audience: Public (Internet)
/ NHS Wales (Intranet)
National Public Health Service for Wales
Rapid Review of Breast Care Services in North Wales
Surgery
On site guide wire insertion

 BTW



Oncoplastic Wide local excision
X
X
X
X

Sentinel node biopsy

X


X but audit phase nearing
completion & hoping to offer
this service as standard in
2009.
Immediate reconstruction (including flap
surgery)
X
X

X

Contralateral symmetrisation surgery
X
X
X
X

Risk reducing surgery and reconstruction
X
X
X
 Risk reducing
surgery
undertaken,
reconstruction
available at CoCH
 After appropriate counselling
Radio guided occult lesion localisation
X
X


X
Twenty four hour anaesthetic cover

X



Twenty four hour surgical cover

X



High dependency unit

X
X


Facilities for Intravenous chemotherapy

X



Intravenous bisphosphonates

X



Intravenous herceptin

X


X
Radiotherapy
X
X

x
X
Adjuvant Therapy
Author: Dr Rob Atenstaedt,
Dr Julia Williams, Mr Andrew Jones
Version: 5
Date: 5/12/08
Page 131 of 132
Status: Approved
Intended Audience: Public (Internet)
/ NHS Wales (Intranet)
National Public Health Service for Wales
Rapid Review of Breast Care Services in North Wales
Recurrent disease
CT scanning

X



MRI scanning

X



Radiotherapy
X
X

x
X
Second line chemotherapy

X



Bone scanning

X



Author: Dr Rob Atenstaedt,
Dr Julia Williams, Mr Andrew Jones
Version: 5
Date: 5/12/08
Page 132 of 132
Status: Approved
Intended Audience: Public (Internet)
/ NHS Wales (Intranet)