west midlands cancer intelligence unit nhsbsp surgical qa data for the year of screening 1 april...
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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
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
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
West Midlands Cancer Intelligence Unit
Setting the scene
Number of cancers and consultant surgeons in the UK NHSBSP
West Midlands Cancer Intelligence Unit
Regions supplying data
Total Cancers
Cancer Detection
Rate
Region(per 1000 screened)
N East, Yorks & Humber 1457 7.2East Midlands 930 7.5East of England 1245 7.6London 1139 7.3South East (East) 863 7.0South East (West) 738 6.7South West 1053 8.0West Midlands 1034 6.9North West 1403 7.4Wales 660 8.4Northern Ireland 216 6.8Scotland 855 6.9United Kingdom 11593 7.3
***
* boundary changes
***
* name changes
West Midlands Cancer Intelligence Unit
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Ca
nce
r d
ete
ctio
n r
ate
Non-invasive & Micro-invasive Invasive Unknown invasive status
Cancer detection rates 2000-03
UK - all cancers6.9 per 1000
UK - non inv/micro 1.5 per 1000
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
2000/01 2001/02 2002/03
Consultant surgeons in the UK NHSBSP 419 439 472
Median screening caseload 17 18 18
% women treated by surgeons with caselaod 20+ 86 85 86
No. surgeons with unexplained low caseload (<10) 25 52 55
West Midlands Cancer Intelligence Unit
Pre-operative diagnosis
X
West Midlands Cancer Intelligence Unit
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10
20
30
40
50
60
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90
100N
E, Y
& H
E M
idla
nds
E of
Eng
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Lond
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ast E
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idla
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th W
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Wal
es
N Ir
elan
d
Sco
tland
Pre
-op
era
tive
dia
gn
osi
s ra
te (
%)
C5 only C5 & B5 B5 only
UK 91%
Min std 80%
Pre-operative diagnosis rate
West Midlands Cancer Intelligence Unit
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20
30
40
50
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80
90
100
Pre
-op
era
tive
dia
gn
osi
s ra
te (
%)
Min std 80%
Pre-operative diagnosis rate
Target 90%
West Midlands Cancer Intelligence Unit
Pre-operative diagnosis rate (7 year comparison)
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10
20
30
40
50
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70
80
90
100
1996/97 1997/98 1998/99 1999/00 2000/01 2001/02 2002/03
Pre
-op
era
tive
dia
gn
osi
s ra
te (
%)
C5+/-B5 C5 only C5&B5 B5 only
West Midlands Cancer Intelligence Unit
Wales
Scotland
0
10
20
30
40
50
60
70
80
90
100
2000/01 2001/02 2002/03
Pre
-op
era
tive
dia
gn
osi
s ra
te (
%)
C5 only C5 & B5 B5 only
0
10
20
30
40
50
60
70
80
90
100
2000/01 2001/02 2002/03
Pre
-op
era
tive
dia
gn
osi
s ra
te (
%)
C5 only C5 & B5 B5 only
3 year comparison
North West0
10
20
30
40
50
60
70
80
90
100
2000/01 2001/02 2002/03
Pre
-op
erat
ive
dia
gn
osi
s ra
te (
%)
C5 only C5 & B5 B5 only
81%
89%
N Ireland
0
10
20
30
40
50
60
70
80
90
100
2000/01 2001/02 2002/03
Pre
-op
era
tive
dia
gn
osi
s ra
te (
%)
C5 only C5 & B5 B5 only
89%
88%
86%
91%
86%
92%
Non inv
West Midlands Cancer Intelligence Unit
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10
20
30
40
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60
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100N
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& H
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idla
nds
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th W
est
Wal
es
N Ir
elan
d
Sco
tland
Inva
sive
Sta
tus
afte
r su
rger
y (%
)
Invasive Micro-invasive Non-invasive No Surgery Unknown
Invasive status after B5a (Non-invasive) core biopsy
UK 24%
33%38%
West Midlands Cancer Intelligence Unit
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10
20
30
40
50
60
70
80
90
100
Inva
sive
Sta
tus
afte
r su
rge
ry (
%)
Invasive Micro-invasive Non-invasive No Surgery Unknown
Invasive status after B5a (Non-invasive) core biopsy
UK 24%
West Midlands Cancer Intelligence Unit
Repeat visits to achieve a pre-operative diagnosis
0
10
20
30
40
50
NE,
Y &
H
E M
idla
nds
E of
Eng
land
Lond
on
S E
ast E
S E
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Sou
th W
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W M
idla
nds
Nor
th W
est
Wal
es
N Ir
elan
d
Sco
tland
Pre
-op
era
tive
dia
gn
osi
s ra
te
(%)
2+ visits Unknown
UK 2+ visits 12%
West Midlands Cancer Intelligence Unit
Diagnostic open biopsies
West Midlands Cancer Intelligence Unit
0.0
0.5
1.0
1.5
2.0
2.5
1996/97 1997/98 1998/99 1999/00 2000/01 2001/02 2002/03
Op
en
bio
psy
ra
te (
pe
r 10
00 s
cre
en
ed
)
Benign Malignant
Open biopsy rates
4749 2734M + 2015B
2919 1018M + 1901B
West Midlands Cancer Intelligence Unit
Open biopsy rates per 1000 women screened
0.00
0.50
1.00
1.50
2.00
2.50
2000/01 2001/02 2002/03Op
en
bio
psy
ra
te (
pe
r 10
00 s
cre
en
ed
)
Benign Malignant
0.00
0.50
1.00
1.50
2.00
2.50
2000/01 2001/02 2002/03Op
en
bio
psy
ra
te (
pe
r 10
00 s
cre
en
ed
)Benign Malignant
North West Wales
Highest rates in UK in 2000/01
West Midlands Cancer Intelligence Unit
Type of surgical treatment provided to non-invasive and
invasive breast cancers
West Midlands Cancer Intelligence Unit
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10
20
30
40
50
60
70
80
90
100
Typ
e o
f tr
ea
tme
nt
(%)
Conservation surgery Mastectomy No surgery Unknown
Treatment for non & micro-invasive cancers 2002/03
UK 69%
West Midlands Cancer Intelligence Unit
0
10
20
30
40
50
60
70
80
90
100
Co
nse
rva
tio
n s
urg
ery
(%
)Treatment for non & micro-invasive cancers 2000-03
UK 69%
West Midlands Cancer Intelligence Unit
High grade multi-focal 28
Large (30+mm) multi-focal 6
Large (30+mm) high grade 90
Large (30+mm) unknown grade 3
Unknown size high grade 54
Unknown size & grade 64
Total* 239
Non-invasive cancers treated by conservation surgery
*counts each cancer once only
Sloane Project data items
grade size
margin status
West Midlands Cancer Intelligence Unit
0
5
10
15
20
25
30
35
40
45
50
55
60
Ma
ste
cto
my
rate
(%
)
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)
4xNEYH
West Midlands Cancer Intelligence Unit
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5
10
15
20
25
30
35
40
45
50
55
60
Ma
ste
cto
my
rate
(%
)
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)
3xNEYH
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
Invasive size
Whole size
50+ mm 81% 88%
20-<50mm 45% 36%
15-<20mm 25% 21%
<15mm 19% 15%
West Midlands Cancer Intelligence Unit
Mastectomy rates according to tumour size
0
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10
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30N
E, Y
& H
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idla
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est
Wal
es
N Ir
elan
d
Sco
tland
Ma
ste
cto
my
rate
(%
)
Invasive size <15mm Whole size <15mm
14% immediate reconstruction
Reconstructionaudit
UK 15% whole size
UK 19% invasive size
*
***
West Midlands Cancer Intelligence Unit
Lymph nodes and invasive grade
West Midlands Cancer Intelligence Unit
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30
32
34
No
da
l st
atu
s u
nkn
ow
n (
%)
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
West Midlands Cancer Intelligence Unit
Insufficient nodal information for invasive cancers
No. %N East, Yorks & Humber 1134 48 28 76 6.7East Midlands 720 27 27 54 7.5East of England 954 83 30 113 11.8London 862 102 51 153 17.7South East (East) 652 29 31 60 9.2South East (West) 596 22 17 39 6.5South West 849 42 25 67 7.9West Midlands 811 11 22 33 4.1North West 1141 74 61 135 11.8Wales 532 5 13 18 3.4Northern Ireland 163 23 1 24 14.7Scotland 672 13 14 27 4.0
UK 9086 479 320 799 8.8
RegionInsufficient nodal
informationTotal
invasive cancers
Unknown nodal status
-ve with <4 nodes
* excludes sentinel nodes
*
West Midlands Cancer Intelligence Unit
02468
10121416182022242628303234
Insu
ffici
ent
no
dal
inf
orm
atio
n (%
)
Unknown nodal status Negative <4 nodes (excl sentinel)
Insufficient nodal information for invasive cancers
UK 8.8%
West Midlands Cancer Intelligence Unit
0
10
20
30
40
50
60N
E, Y
& H
E M
idla
nds
E o
fE
ngla
nd
Lond
on
S E
ast E
S E
ast W
Sou
th W
est
W M
idla
nds
Nor
th W
est
Wal
es
N Ir
elan
d
Sco
tland
Nod
al s
tatu
s (%
)
Nodal status known Unknown if nodes obtained
Non-invasive cancers with known nodal status
UK 26%
41% mastectomiesUK 29%
West Midlands Cancer Intelligence Unit
0
10
20
30
40
50
60
70
80
90
100
B5a +/- C5 B5b +/- C5 B5c/u C5 only No C5/B5
Nod
al s
tatu
s kn
own
(%)
81
25
4
21
13
Nodal status and pre-operative history
Why take nodes for B5a? conservatively treated
non-invasive cancers
West Midlands Cancer Intelligence Unit
0
10
20
30
40
50
60
70
80
90
100
Gra
de
(%
)
I II III Not assessable Unknown1 unit no data
Invasive grade
West Midlands Cancer Intelligence Unit
0
10
20
30
40
50
60
70
80
90
100
NP
I G
rou
p (
%)
EPG GPG MPG1 MPG2 PPG
NPI
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
West Midlands Cancer Intelligence Unit
0
5
10
15
20
25N
E, Y
& H
E M
idla
nds
E of
Eng
land
Lond
on
S E
ast E
S E
ast W
Sou
th W
est
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idla
nds
Nor
th W
est
Wal
es
N Ir
elan
d
Sco
tland
Re
pe
at
Op
era
tio
n R
ate
(%
)
Invasive Non-invasive
Repeat operation rates
UK 14% invasive
UK 16% non-invasive
West Midlands Cancer Intelligence Unit
Repeat operations - possible scenarios
B5a (non invasive) invasive after surgeryInvasion not predicted by pre-operative diagnosis
- repeat operation to obtain nodes
C5 nodes not taken at first operation1
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
West Midlands Cancer Intelligence Unit
B5b (Invasive) : invasiveafter surgery - 6743 cases
Cons. &Ax
Mx. & Ax Cons. Mx.
Cons.
Mx.
Mx.
4154 cases, 62% 1458 cases, 22% 230 cases, 3% 56 cases, 1%
355 cases, 5% 214 cases, 3%
34 cases, 1%
Mx. & Ax
46 cases, 1%
17 (0%) Unknown,9 (0%) Ax only,
29 (0%) Other no AX,87 (1%) Other Ax at 1st op,54 (1%) Other Ax at later op
B5b invasive after surgery
5% no Ax
84% 1 operation inc Ax
12% repeat operation
West Midlands Cancer Intelligence Unit
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20
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40
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60
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80
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NE,
Y &
H
E M
idla
nds
E of
Eng
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Lond
on
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idla
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Nor
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Wal
es
N Ir
elan
d
Sco
tland
Ax
illa
ry s
urg
ery
(%
)
First surgery Later surgery
Nodal status for B5b invasive after surgery
UK 94% first operation1% repeat operation
31% no Ax surgery
West Midlands Cancer Intelligence Unit
C5, no B5, invasive - 1126 cases
Cons. &Ax
Mx. & Ax Cons. Mx.
Cons.
Mx.
720 cases, 64% 185 cases, 16% 39 cases, 3% 19 cases, 2%
49 cases, 4% 29 cases, 3%
6 cases, 1%
15 cases, 1%
Mx. Mx. & AxCons. &
AxAx
15 cases, 1%
14 cases, 1%
8 cases, 1%
Ax.
6 (1%) Unknown,6 (1%) No Surgery,
2 (0%) Ax only,3 (0%) Other no AX,
7 (1%) Other Ax at 1st op,3 (0%) Other Ax at later op
C5 only invasive cancers80% 1 operation inc Ax
13% repeat operation
5% no Ax
West Midlands Cancer Intelligence Unit
0
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NE,
Y &
H
E M
idla
nds
E of
Eng
land
Lond
on
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ast E
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th W
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idla
nds
Nor
th W
est
Wal
es
N Ir
elan
d
Sco
tland
Ax
illa
ry s
urg
ery
(%
)
First surgery Later surgery
Nodal status C5 only invasive after surgery
UK 91% first operation3% repeat operation
23% no Ax surgery
16% no Ax surgery
West Midlands Cancer Intelligence Unit
B5a (Non-invasive) : invasive aftersurgery - 548 cases
Mx. & AxCons. &
AxCons. Mx.
Mx.
129 cases, 24% 124 cases, 23% 53 cases, 10%
16 cases, 3%
10 cases, 2%
8 cases, 1%
Cons.
Ax 6 cases, 1%
Cons. &Ax
68 cases, 12%
63 cases, 11%
37 cases, 7%
Ax. Mx & Ax
7 cases, 1%
Cons.
Mx
7 cases, 1%2 (0%) Unknown,
2 (0%) Other no AX,4 (1%) Other Ax at 1st op,6 (1%) Other Ax at later op
Mx & AxCons. &
Ax
3 cases, 1%
3 cases, 1%
B5a invasive cancers46% 1 operation inc Ax
14% no Ax
34% Ax at repeat operation
41% repeat operation
West Midlands Cancer Intelligence Unit
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NE,
Y &
H
E M
idla
nds
E of
Eng
land
Lond
on
S E
ast E
S E
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th W
est
W M
idla
nds
Nor
th W
est
Wal
es
N Ir
elan
d
Sco
tland
Ax
illa
ry s
urg
ery
(%
)
First surgery Later surgery
Nodal status B5a invasive after surgery
UK 51% first operation34% repeat operation
60% at repeat op
24% no Ax surgery
31% no Ax surgery
70% at first op
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? ?
West Midlands Cancer Intelligence Unit
Data completeness for RT, CT, HT start dates
0
10
20
30
40
50
60
70
80
90
100N
E, Y
& H
E M
idla
nds
E of
Eng
land
Lond
on
S E
ast E
S E
ast W
Sou
th W
est
W M
idla
nds
Nor
th W
est
Wal
es
N Ir
elan
d
Sco
tland
Da
ta c
om
ple
ten
ess
(%
)
RT, CT, HT complete RT, CT complete
84% some data supplied (77% last year)
76% RT, CT complete
UK 72% RT, CT, HT complete
West Midlands Cancer Intelligence Unit
0
10
20
30
40
50
60
70
80
90
100N
E, Y
& H
E M
idla
nds
E of
Eng
land
Lond
on
S E
ast E
S E
ast W
Sou
th W
est
W M
idla
nds
Nor
th W
est
Wal
es
N Ir
elan
d
Sco
tland
ER
no
t d
on
e o
r u
nkn
ow
n (
%)
Invasive Non-invasive
Unknown ER status
UK 63% non-invasiveUK 9% invasive
West Midlands Cancer Intelligence Unit
Data completeness for PgR status
0
10
20
30
40
50
60
70
80
90
100N
E, Y
& H
E M
idla
nds
E of
Eng
land
Lond
on
S E
ast E
S E
ast W
Sou
th W
est
W M
idla
nds
Nor
th W
est
Wal
es
N Ir
elan
d
Sco
tland
Pg
R s
tatu
s kn
ow
n (
%)
All cancers ER Negative
UK 30% known all cancers UK 50% known
for ER –ve cancers
West Midlands Cancer Intelligence Unit
0
10
20
30
40
50
60
70
80
90
100N
E, Y
& H
E M
idla
nds
E of
Eng
land
Lond
on
S E
ast E
S E
ast W
Sou
th W
est
W M
idla
nds
Nor
th W
est
Wal
es
N Ir
elan
d
Sco
tland
Ce
rb-B
2/H
ER
-2 s
tatu
s kn
ow
n (
%)
Data completeness for Cerb-B2/HER-2 status
UK 11%
West Midlands Cancer Intelligence Unit
Times to first treatment and from first treatment to
adjuvant therapy
West Midlands Cancer Intelligence Unit
Median days between therapies
Shading:orange10% above UK, green 10% below UK
RT RT CT CT
(1 op) (>1 op) (1 op) (>1 op)
N East, Yorks & Humber 30 27 78 106 42 63
East Midlands 32 28 62 90 38 78
East of England 28 27 90 114 31 63
London 35 30 92 119 40 90
South East (East) 43 40 95 127 41 80
South East (West) 22 25 104 129 33 62
South West 34 30 67 88 43 78
West Midlands 33 22 67 103 37 58
North West 33 28 76 131 40 61
Wales 22 23 72 101 43 66
Northern Ireland 28 14 69 111 37 35
Scotland 29 26 56 87 35 64
UK 30 27 73 103 38 66
Final surgery to...
Diag surgery
Therap surgery
Region
Assessment to...
West Midlands Cancer Intelligence Unit
0
5
10
15
20
25N
E, Y
& H
E M
idla
nds
E of
Eng
land
Lond
on
S E
ast E
S E
ast W
Sou
th W
est
W M
idla
nds
Nor
th W
est
Wal
es
N Ir
elan
d
Sco
tland
HT
be
fore
fir
st s
urg
ery
(%
)
Hormone Therapy before first surgery
UK 10% (12% last year)
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
3Hormonal Therapy (eg. Tamoxifen) is only beneficial to women with ER positive tumours and ER negative PgR positive tumours
West Midlands Cancer Intelligence Unit
0
10
20
30
40
50
60
70
80
90
100N
E, Y
& H
E M
idla
nds
E of
Eng
land
Lond
on
S E
ast E
S E
ast W
Sou
th W
est
W M
idla
nds
Nor
th W
est
Wal
es
N Ir
elan
d
Sco
tland
Wit
ho
ut
RT
(%
)
Invasive Non-invasive
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 conservativelytreated cancers
West Midlands Cancer Intelligence Unit
0
10
20
30
40
50
60
70
80
90
100N
E, Y
& H
E M
idla
nds
E of
Eng
land
Lond
on
S E
ast E
S E
ast W
Sou
th W
est
W M
idla
nds
Nor
th W
est
Wal
es
N Ir
elan
d
Sco
tland
Wit
h C
T (
%)
ER Negative Node Positive ER Negative Node Negative
ER -ve invasive cancers receiving chemotherapyUK 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
West Midlands Cancer Intelligence Unit
0
10
20
30
40
50
60
70
80
90
100N
E, Y
& H
E M
idla
nds
E of
Eng
land
Lond
on
S E
ast E
S E
ast W
Sou
th W
est
W M
idla
nds
Nor
th W
est
Wal
es
N Ir
elan
d
Sco
tland
Wit
ho
ut
HT
(%
)
Invasive Non-invasive
ER +ve cancers not receiving hormonal therapy
527 ER +ve cancers (9%) did not receive HT
UK 33% non-invasive
UK 7% invasive
West Midlands Cancer Intelligence Unit
0
5
10
15
20
25
30
35
40N
E, Y
& H
E M
idla
nds
E of
Eng
land
Lond
on
S E
ast E
S E
ast W
Sou
th W
est
W M
idla
nds
Nor
th W
est
Wal
es
N Ir
elan
d
Sco
tland
Wit
h H
T (
%)
0
ER -ve cancers receiving hormonal therapy
30/45 (67%) ER -ve PgR +veand 49/360 (14%) ER -ve PgR -ve
cancers received HTUK 16%
West Midlands Cancer Intelligence Unit
Survival analyses for screen-detected cancers diagnosed
1st April 1992 - 31st March 1998
West Midlands Cancer Intelligence Unit
Relative survival for invasive cancers
85
90
95
100
0 1 2 3 4 5 6 7 8 9 10
Years
Re
lati
ve S
urv
iva
l (%
)
1992/93 1993/94 1994/95 1995/96 1996/97 1997/98
10 year survival for 1992/93 cases, 87.8%
5 year survival for 1997/98 cases, 95.8%
West Midlands Cancer Intelligence Unit
50
55
60
65
70
75
80
85
90
95
100
EPG GPG MPG1 MPG2 PPG
Rel
ativ
e S
urv
ival
(%)
1992/93-1994/95 1993/94-1995/96 1994/95-1996/97 1995/96-1997/98
5 year relative survival and NPI
59% of cases with known NPI are EPG/GPG
West Midlands Cancer Intelligence Unit
Download the audit (booklet and presentation)
from
www.wmpho.org.uk/wmciu
and
www.cancerscreening.nhs.uk
West Midlands Cancer Intelligence Unit