How clinical audit is helping the NHS improve the entire breast cancer pathway

1 Oct 2026

October 2026 is Breast Cancer Awareness Month – find out more about HQIP’s work on this topic in our NEW breast cancer care hub

For everyone diagnosed with breast cancer, the journey from diagnosis through treatment and beyond is life changing. Each patient’s experience is unique, but breast cancer services aim to provide timely, high-quality care to people that responds to their individual circumstances, and the type of breast cancer they have.

Delivering on this aim is a significant challenge for the NHS. While advances in diagnostic processes and treatment continue to improve outcomes for many with breast cancer, it is important that we understand whether those improvements are delivering results for all patients. This is where clinical audit plays a vital role as one of the NHS’ key improvement tools, and helps health providers to understand what parts of the care pathway are working well – and what are not – and ensure improvements benefit patients at every stage of their experience.

As the NHS works to deliver the ambitions set out in the NHS 10 Year Health Plan for England and the National Cancer Plan for England, understanding how care is delivered becomes increasingly important. National cancer audits, including the National Audit of Primary Breast Cancer (NAoPri) and the National Audit of Metastatic Breast Cancer (NAoMe), delivered as part of the National Cancer Audit Collaborating Centre (NATCAN) commissioned by Healthcare Quality Improvement Partnership (HQIP), produce robust evidence that helps services understand how breast cancer care is being delivered across England and Wales. Publicly available information is provided for each breast unit, at a regional level (Cancer Alliance in England) and national level, enabling the benchmarking of performance, the identification of unwarranted variation, and the prioritisation of actions where it will have the greatest impact.

“A breast cancer diagnosis comes as a shock to most and is accompanied by a myriad of decisions with long term consequences that require careful consideration during what can be a very turbulent time. The equitable presentation of information about all treatment options and their universal availability across the UK is paramount to patient satisfaction.

The clinical data routinely recorded about every patient care episode in the NHS provides the UK audit teams with the unique ability to compare the care provided by different Cancer Alliances and identify areas of variability; they are then uniquely positioned to analyse the cause and subsequently improve patient care. The opportunity for patient advocates to sit on the NAoPri and NAoMe panels and provide feedback on the data output ensures it is considered with patients interests at the heart of discussions with those delivering care at the front line.

As an example of this, one of the primary targets of the NAoPri is to improve the rates of, and equitable access to, immediate breast reconstruction. From a patient perspective this has to be balanced against the need to make such a big decision at the point of diagnosis and therefore requires the care pathway to provide sufficient clinic time for full and open discussions about patient values, lifestyle and expectations along with an evidence-based presentation of what treatments are clinically appropriate.”

Sam Brunsden, Patient Representative/Research Advisor Flat Friends

Breast cancer: Understanding care from diagnosis onwards

Both the NAoPri and NAoMe audits have highlighted the importance of Triple Diagnostic Assessment (TDA), combining clinical examination, imaging, and tissue sampling at the initial consultation. This approach supports timely and accurate diagnosis, helping to reduce uncertainty for patients. The National Cancer Plan identifies earlier and more effective diagnosis as a critical factor in improving outcomes, making the audit’s focus on diagnostic pathways particularly important. NAoPri’s latest State of the Nation report, published September 2026, showed that in England and Wales between 2021 and 2023, only 68% of patients diagnosed with early breast cancer had a TDA, although this was a small improvement from 66% in the previous period (2020-2022). There was also marked variation between breast units; and so this metric will remain an audit focus.

The support provided by clinical nurse specialists (CNS) during the diagnostic process is invaluable and recognised as such by all major clinical guidelines. Among patients for whom CNS information was available, 94% had CNS contact – close to the expectation in NICE Quality Standard 12 statement 6 that all patients with breast cancer should be assigned a named CNS or other specialist key worker.

Breast cancer treatment is also increasingly personalised. Surgery, drug therapy, and radiotherapy all play important roles, depending on an individual’s diagnosis and preferences. The audits are helping services assess whether patients have equitable access to these treatment options and identify where practice is changing over time.

Amongst the many treatment options available, the audits have focused recently on the use of neo-adjuvant chemotherapy and uptake of immediate breast reconstruction. There has been increased use of neoadjuvant chemotherapy over the last decade among groups for whom it is recommended, a treatment approach that can reduce tumour size before surgery and inform subsequent treatment. In the latest audit period, 56% of people with stage 2 to 3A triple-negative or HER2-positive breast cancer received treatment before surgery.

Access to immediate breast reconstruction (IBR) following mastectomy is beginning to recover following the disruption caused by the COVID-19 pandemic. IBR refers to reconstruction of the breast at the same time as mastectomy. For women undergoing mastectomy, it is an important surgical option that provides potential psychological benefits. Just over a quarter of women undergoing mastectomy had an immediate reconstruction (2021-23).

The audit also found that around one in six people required a further operation following breast-conserving surgery to achieve clear margins of disease. The rate was 27% for ductal carcinoma in situ, compared with the NAoPri target of 15%, and 15% for invasive disease, compared with a target of 10%. On this measure, as well as many others within the audit, organisational rates ranged significantly, giving services a clear national benchmark against which to review their practice. Identifying unwarranted variation and supporting improvement in this way is a core function of clinical audit. While differences in patient populations will always influence treatment decisions, understanding why outcomes and practices vary can help organisations learn from one another and improve care across the system.

What outcomes can tell us

In England and Wales, 3-year all-cause survival and breast cancer-specific survival among people diagnosed with stage 1 to 3A invasive breast cancer between 2022 and 2023 were 92% and 98%, respectively. Notably, the audit has recently implemented a process to identify providers which are outliers for 3-year survival.

Metastatic breast cancer: Bringing new visibility to this stage of the pathway

The National Audit of Metastatic Breast Cancer (NAoMe) is the only NATCAN audit dedicated to assessing the care of patients with metastatic disease. Patients either present with metastatic disease (de novo) or metastatic disease diagnosed following previous diagnosis of primary breast cancer (recurrent).

“For those of us living with metastatic breast cancer, data is far more than numbers. It is a vital tool for identifying inequalities in care, addressing unwarranted variation and ensuring that every patient has access to the best possible treatment and support, wherever they live. By turning data into meaningful improvements in services, we can work towards what patients want most: a better quality of life and improved survival outcomes.”

Carla Whitbread, NAoME Patient Representative with MBC Lived Experience 

One of the five quality improvement goals adopted by the NAoMe is to “improve the movement of patients through the care pathway”. National and international guidelines recommend that a Multidisciplinary Team (MDT) considers the management options for people with metastatic breast cancer, because it supports coordinated, individualised treatment planning and helps ensure care is consistent with clinical guidelines, including NICE guidance. The NAoMe 2026 State of the Nation report highlights that during 2021-2023, 81% of patients with de novo disease across England and Wales were discussed in an MDT meeting (against the audit target of 90%).

There are also encouraging signs in access to specialist support and treatment. Recorded CNS contact in England increased from 59% to 62% (2020-2022 vs 2021-2023), while the proportion of eligible patients receiving HER2-targeted treatment increased from 72% to 75% – modest but important movements.

Similar to NAoPri, care variation was commonly identified but, again, this is where the audit working together with the wider cancer care sector can make a difference. By shining a light on metastatic breast cancer care, their work helps ensure that improvement efforts extend beyond diagnosis and initial treatment, including areas that have historically received less attention.

One of the most significant developments in breast cancer care is the major focus on identifying when a person has metastatic recurrence. Understanding when this occurs is essential for evaluating treatment effectiveness, planning services, and improving long-term outcomes. NAoMe’s work has already produced practical guidance for hospital-level data entry, helped identify approximately 6,000 additional people through the exploration of treatment and radiotherapy datasets, and brought together seven UK organisations through a data improvement group. By working with National Disease Registration Service (NDRS) and other partners in strengthening the recording of recurrence, the audits are contributing to a more complete picture than has previously been possible – aligning with national ambitions to strengthen the use of data to improve service planning.

Turning insight into improvement: Further opportunities for the future

The growing availability and use of national cancer data creates an important opportunity to make the picture of breast cancer care increasingly complete, timely, and useful. Continued work to improve the completeness and consistency of routinely collected NHS data will strengthen further the insights provided by NAoPri and NAoMe, enabling services to make fairer comparisons and understand patients’ experiences more fully.

Provider-level dashboards, targeted feedback, and practical improvement resources are already helping NHS organisations review their results and identify priorities for action. Alongside these resources, specific quality improvement initiatives are helping to address areas highlighted by the audit findings, and continued, proactive focus on this work will be important in supporting further progress. As an example of this improvement, NAoPri’s work on immediate breast reconstruction supports organisations to understand their results and explore potential barriers relating to service configuration, capacity, referral pathways, and shared decision-making. NAoMe’s work on the recording of breast cancer recurrence is similarly combining practical guidance for local teams with national collaboration and the exploration of additional data sources.

This work aligns closely with national priorities in England and Wales, to improve the use of data, reduce unwarranted variation, and translate evidence into practice. National clinical audit is not simply a means of measuring care, but an important part of the infrastructure for improving it.

As data and quality improvement approaches continue to develop, NAoPri and NAoMe are well placed to bring together evidence, clinical expertise, patient perspectives, and practical support for local action, helping the NHS understand whether advances in diagnosis and treatment are reaching patients consistently and equitably. For everyone affected by breast cancer, the goal is simple: that wherever they live, whatever their circumstances, and wherever they are treated, they can have confidence in receiving the best possible care throughout their journey.

Further resources from HQIP

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