1. West Midlands Cancer Intelligence Unit NHSBSP Surgical QA Data for the Year of Screening 1 April 2002 to 31 March 2003 Dr Gill Lawrence and Professor Jan Frisell on behalf of ABS at BASO

2. West Midlands Cancer Intelligence Unit Acknowledgements Mr Hugh Bishop Mr James Bristol Mr Mark Kissin Dr Gill Lawrence Mrs Julietta Patnick Ms Jacquie Reed Ms Nicola Richmond Prof Paul Sauven Dr Matthew Wallis Dr Jackie Walton Mrs Margot Wheaton The BASO Breast Audit Group would like to extend their thanks to all NHS and ABS at BASO staff who contributed to the 2002/03 ABS at BASO Breast Audit

3. West Midlands Cancer Intelligence Unit Acknowledgements ABS at BASO Surgical QA Co-ordinators Ms Lucy Davies Breast Screening QA Reference Centres QA Directors QA Co-ordinators QA Data Managers Screening Services Screening Office Managers Surgeons Regional Cancer Registries West Midlands Cancer Intelligence Unit

4. Setting the scene Number of cancers and consultant surgeons in the UK NHSBSP

5. West Midlands Cancer Intelligence Unit Regions supplying data * * * * boundary changes * * * * name changes

6. West Midlands Cancer Intelligence Unit Cancer detection rates 2000-03 UK - all cancers 6.9 per 1000 UK - non inv/micro 1.5 per 1000

7. West Midlands Cancer Intelligence Unit Screening surgical caseload Surgical specialisation most advanced in West Midlands and Northern Ireland In North West, 60 women were under the care of more than one consultant surgeon London and East of England were unable to provide a reason for low caseload for more than 20 surgeons

8. West Midlands Cancer Intelligence Unit Pre-operative diagnosis X

9. West Midlands Cancer Intelligence Unit UK 91% Min std 80% Pre-operative diagnosis rate

10. West Midlands Cancer Intelligence Unit Min std 80% Pre-operative diagnosis rate Target 90%

11. West Midlands Cancer Intelligence Unit Pre-operative diagnosis rate (7 year comparison)

12. West Midlands Cancer Intelligence Unit Wales Scotland 3 year comparison North West 81% 89% N Ireland 89% 88% 86% 91% 86% 92% Non inv

13. West Midlands Cancer Intelligence Unit Invasive status after B5a (Non- invasive) core biopsy UK 24% 33% 38%

14. West Midlands Cancer Intelligence Unit Invasive status after B5a (Non- invasive) core biopsy UK 24%

15. West Midlands Cancer Intelligence Unit Repeat visits to achieve a pre- operative diagnosis UK 2+ visits 12%

16. West Midlands Cancer Intelligence Unit Diagnostic open biopsies

17. West Midlands Cancer Intelligence Unit Open biopsy rates 4749 2734M + 2015B 2919 1018M + 1901B

18. West Midlands Cancer Intelligence Unit Open biopsy rates per 1000 women screened North West Wales Highest rates in UK in 2000/01

19. West Midlands Cancer Intelligence Unit Type of surgical treatment provided to non-invasive and invasive breast cancers

20. West Midlands Cancer Intelligence Unit Treatment for non & micro- invasive cancers 2002/03 UK 69%

21. West Midlands Cancer Intelligence Unit Treatment for non & micro- invasive cancers 2000-03 UK 69%

22. West Midlands Cancer Intelligence Unit Non-invasive cancers treated by conservation surgery *counts each cancer once only Sloane Project data items grade size margin status

23. West Midlands Cancer Intelligence Unit Treatment for all invasive cancers 2000-03 UK 28% Yellow line through the Midlands (East and West) Blue above this line (Scotland, N Ireland, NEYH, North West, Wales) Red below this line (E of England, London, South East (E & W), South West) 4x NEYH

24. West Midlands Cancer Intelligence Unit Treatment for invasive cancers <15mm 2000-03 UK 20% Yellow line through the Midlands (East and West) Blue above this line (Scotland, N Ireland, NEYH, North West, Wales) Red below this line (E of England, London, South East (E & W), South West) 3x NEYH

25. West Midlands Cancer Intelligence Unit Mastectomy rates according to tumour size Mastectomy rates are lower if whole size is taken into consideration Presence of DCIS increases mastectomy rate

26. West Midlands Cancer Intelligence Unit Mastectomy rates according to tumour size 14% immediate reconstruction Reconstruction audit UK 15% whole size UK 19% invasive size * * * *

27. West Midlands Cancer Intelligence Unit Lymph nodes and invasive grade

28. West Midlands Cancer Intelligence Unit Invasive cancers with nodal status unknown UK 5.3% 10 units complete nodal information 7/8 London units >2x UK average 1 unit complete nodal info for 2000-03

29. West Midlands Cancer Intelligence Unit Insufficient nodal information for invasive cancers * excludes sentinel nodes *

30. West Midlands Cancer Intelligence Unit Insufficient nodal information for invasive cancers UK 8.8%

31. West Midlands Cancer Intelligence Unit Non-invasive cancers with known nodal status UK 26% 41% mastectomies UK 29%

32. West Midlands Cancer Intelligence Unit Nodal status and pre- operative history Why take nodes for B5a? conservatively treated non-invasive cancers

33. West Midlands Cancer Intelligence Unit 1 unit no data Invasive grade

34. West Midlands Cancer Intelligence Unit NPI

35. West Midlands Cancer Intelligence Unit Repeat therapeutic operations 90% of cancers with single lesions (excluding multi- focal tumours and those with extensive DCIS) should not require a further operation to ensure complete excision

36. West Midlands Cancer Intelligence Unit Repeat operation rates UK 14% invasive UK 16% non-invasive

37. West Midlands Cancer Intelligence Unit Repeat operations - possible scenarios B5a (non invasive) invasive after surgery Invasion not predicted by pre-operative diagnosis - repeat operation to obtain nodes C5 nodes not taken at first operation 1 Margins not clear - repeat operation conservation or mastectomy 2 3 Expected tumour component Small B5b (invasive) with unexpected DCIS Additional nodal procedure Insufficient no. obtained at 1st operation Therapeutic clearance after large no. +ve Clearance after +ve sentinel node 4

38. West Midlands Cancer Intelligence Unit B5b invasive after surgery 5% no Ax 84% 1 operation inc Ax 12% repeat operation

39. West Midlands Cancer Intelligence Unit Nodal status for B5b invasive after surgery UK 94% first operation 1% repeat operation 31% no Ax surgery

40. West Midlands Cancer Intelligence Unit C5 only invasive cancers 80% 1 operation inc Ax 13% repeat operation 5% no Ax

41. West Midlands Cancer Intelligence Unit Nodal status C5 only invasive after surgery UK 91% first operation 3% repeat operation 23% no Ax surgery 16% no Ax surgery

42. West Midlands Cancer Intelligence Unit B5a invasive cancers 46% 1 operation inc Ax 14% no Ax 34% Ax at repeat operation 41% repeat operation

43. West Midlands Cancer Intelligence Unit Nodal status B5a invasive after surgery UK 51% first operation 34% repeat operation 60% at repeat op 24% no Ax surgery 31% no Ax surgery 70% at first op

44. West Midlands Cancer Intelligence Unit Adjuvant therapies Which pathways were followed? How long did it take to get there? What combinations of treatments were given? ?

45. West Midlands Cancer Intelligence Unit Data completeness for RT, CT, HT start dates 84% some data supplied (77% last year) 76% RT, CT complete UK 72% RT, CT, HT complete

46. West Midlands Cancer Intelligence Unit Unknown ER status UK 63% non-invasive UK 9% invasive

47. West Midlands Cancer Intelligence Unit Data completeness for PgR status UK 30% known all cancers UK 50% known for ER –ve cancers

48. West Midlands Cancer Intelligence Unit Data completeness for Cerb-B2/HER-2 status UK 11%

49. West Midlands Cancer Intelligence Unit Times to first treatment and from first treatment to adjuvant therapy

50. West Midlands Cancer Intelligence Unit Median days between therapies Shading:orange10% above UK, green 10% below UK

51. West Midlands Cancer Intelligence Unit Hormone Therapy before first surgery UK 10% (12% last year)

52. West Midlands Cancer Intelligence Unit Propositions for discussion 1 Women treated with conservation surgery should normally receive radiotherapy Women with ER negative, node positive invasive tumours should normally receive chemotherapy 2 3 Hormonal Therapy (eg. Tamoxifen) is only beneficial to women with ER positive tumours and ER negative PgR positive tumours

53. West Midlands Cancer Intelligence Unit Proportion of cancers not receiving radiotherapy UK 11% invasive UK 52% non-invasive 49% high grade 30% 15+mm 38% high grade 44% 15+mm 81 invasive 20+mm conservatively treated cancers

54. West Midlands Cancer Intelligence Unit ER -ve invasive cancers receiving chemotherapy UK 85% node +ve UK 49% node -ve Only 28 ER -ve node +ve cancers did not receive CT 84% of the ER -ve node -ve cancers with CT were Grade III

55. West Midlands Cancer Intelligence Unit ER +ve cancers not receiving hormonal therapy 527 ER +ve cancers (9%) did not receive HT UK 33% non-invasive UK 7% invasive

56. West Midlands Cancer Intelligence Unit ER -ve cancers receiving hormonal therapy 30/45 (67%) ER -ve PgR +ve and 49/360 (14%) ER -ve PgR -ve cancers received HT UK 16%

57. West Midlands Cancer Intelligence Unit Survival analyses for screen-detected cancers diagnosed 1st April 1992 - 31st March 1998

58. West Midlands Cancer Intelligence Unit Relative survival for invasive cancers 10 year survival for 1992/93 cases, 87.8% 5 year survival for 1997/98 cases, 95.8%

59. West Midlands Cancer Intelligence Unit 5 year relative survival and NPI 59% of cases with known NPI are EPG/GPG

60. West Midlands Cancer Intelligence Unit Download the audit (booklet and presentation) from www.wmpho.org.uk/wmciu and www.cancerscreening.nhs.uk

61. West Midlands Cancer Intelligence Unit