5 October 2009: Audit shows breast cancer patients have increased access to immediate reconstructive surgery, but highlights the need for more improvement
One in five women with breast cancer in England have an immediate reconstruction at the time of their mastectomy, compared to one in nine in 2006, according to the second report from the National Mastectomy and Breast Reconstruction Audit.
The proportion of women offered or undergoing immediate reconstruction also varies significantly by region according to the audit, published today by the NHS Information Centre and the Royal College of Surgeons on behalf of the Healthcare Quality Improvement Partnership.
The National Institute for Health and Clinical Excellence (NICE) recommends immediate breast reconstruction should be discussed with all patients who are advised to have a mastectomy and should be offered to all, except where a patient's health or treatment plan would make them unsuitable for the procedure.
The audit also raises questions about how the offer of immediate reconstruction is communicated to patients, after it found the proportion of women who accepted an offer varied regionally from 17 per cent in one cancer network to 62 per cent in another, despite the procedure being regarded as safe for most women.
Six non-English NHS trusts, 106 independent hospitals and all 150 English NHS trusts that provide breast cancer surgery, participated in the audit which was able to examine about 74 per cent of all cases involving adult women who had mastectomy or reconstructive breast surgery between January 1 2008 and March 31 2009. The audit found:
The audit notes the increased demand for breast cancer surgery during the last decade due to the corresponding increase in the incidence of the disease. The number of breast cancer operations increased from 24, 684 in 1997 to 33,814 in 2006, a 37 per cent increase.
Its recommendations include:
NHS Information Centre Chief Executive Tim Straughan said: "This is the second of four reports from the National Mastectomy and Breast Cancer Audit, which is the first of its kind in the world and provides the NHS with the comprehensive information it needs to better plan and improve breast cancer surgery services.
"The fact that all NHS trusts in England that provide breast cancer surgery took part in the audit shows an excellent commitment from all those involved with the care of breast cancer patients and a desire to contribute to this very important study. The audit clearly shows an improvement in the proportion of women having immediate reconstruction but highlights the need to improve access and the way the procedure is offered to patients."
Robin Burgess, Chief Executive of the Healthcare Quality Improvement Partnership, said "It is important that women with breast cancer who have a mastectomy are offered the choice of breast reconstruction immediately. This can not only help reduce the number of operations needed but also minimise the psychological impact of a mastectomy.
"This is a failure to offer patients the choice they are entitled to, one for which they should have access to better information. Patients have a right to be treated as equals in their choice of treatment, in-line with clinical recommendations and best practice.
"This audit, as with several audits in our national programme, highlights the shortfalls occurring and makes recommendations which can directly lead to improvements in the level of care received by patients."
Consultant General and Oncoplastic Breast Surgeon and clinical lead for the audit, Jerome Pereira, said: "This audit has the potential to improve quality and outcomes following breast cancer surgery, worldwide.
The enthusiasm and commitment of surgeons to provide high quality care for our patients is demonstrated by the fact that all 150 English NHS Trusts and 106 independent hospitals are committed to the programme. Though it is encouraging to note a doubling in reconstruction surgery rates, there are key lessons to be learnt from this second annual report. Cancer networks have a responsibility in implementing the key recommendations in order to improve communication and access and increase resources to provide breast reconstruction within the 31 day target."
Breast cancer nurse and audit project team member, Carmel Sheppard, said: "This audit provides significant information to breast care nurses, who play a pivotal role in supporting women throughout the patient journey. Breast care nurses have a central role in providing information to patients to facilitate choice and decision making regarding treatment.
"It is fantastic news that access to reconstruction has increased and this audit provides us with new opportunities to now explore potential difficulties that some units have. As nurses we must continue to advocate for greater patient access ensuring that all women suitable for reconstructive surgery are provided with equal opportunities to access their treatment of choice.
Consultant Reconstructive Plastic Surgeon Chris Caddy, audit representative for the British Association of Plastic, Reconstructive and Aesthetic surgeons said: "We are delighted with publication of this report which confirms the continuing improvement in care for women diagnosed with breast cancer. It shows a significant improvement in the number of patients who are offered and undergo immediate breast reconstruction in the two years since the audit was launched. We are excited to see the high level of engagement from breast care teams across England with all 150 centres involved with these patients, enrolling patients into the audit. The Report confirms the fundamental need for all groups of carers to work collaboratively to improve levels of care and in particular outcomes for these patients. This is very much a "world first" which will allow improved counselling of patients with regards to complication and outcomes. We are very proud of what we have achieved to date.
"There are challenges that have been highlighted and these need to be looked at carefully. There is huge variation in access to reconstruction both in the way that the opportunities are communicated and surgical expertise is made available. Huge strides have been made in developing onco-plastic approaches to the management of patients with breast cancer, but there is a well defined group who would benefit from some of the more complex procedures, such as moving tissues and rebuilding the breast using microsurgical techniques. These procedures are mainly performed by plastic surgeons and we see the need to improve our availability. The British Association of Plastic Reconstructive and Aesthetic Surgeons are already aware of some of these short comings and are working with the Association of Breast Surgeons to improve training and ultimately access to the full spectrum of reconstructive options. As a plastic surgeon I want to see our group being more actively engaged, with a physical presence on every Breast Multi Disciplinary Team (MDT) throughout the United Kingdom. We have the drive and determination to make this a reality."
The audit can be accessed here.
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