Variable access to treatments criticised

Demand for breast cancer surgery during the last decade has risen by 37% due to an increase in the incidence of the disease.1 But are patients being offered equal access to treatment options and, if not, why? Regional variations in availability of resources, attitudes to age, and current waiting time targets have all been identified as possible factors limiting patients’ choices. Over recent years there have been important developments in the investigation and management of breast cancer including new types of chemotherapy, and biological and hormonal agents. However, there is evidence of practice variation across the country and of inconsistent availability of certain treatments and procedures. The National Institute for Health and Clinical Excellence (NICE) sought to address some of these issues with the publication of two key documents, earlier this year, on the management and treatment of early and advanced breast cancer. The guidance recommends that clinicians offer endocrine therapy as firstline treatment for the majority of patients with oestrogen receptor (ER) positive advanced breast cancer. For patients who are receiving treatment with trastuzumab for advanced breast cancer,2 NICE recommends that treatment with trastuzumab is discontinued at the time of disease progression outside the central nervous system. However, it should not be discontinued if disease progression is within the central nervous system alone. 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 Improving outcomes in breast cancer: manual update (NICE cancer service guidance 2002) and Improving supportive and palliative care for adults with cancer (NICE cancer service guidance 2004). 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. The guidelines further recommend that clinicians consider offering bisphosphonates to patients who are newly diagnosed with bone metastases, to prevent skeletalrelated events and to reduce pain. Furthermore, they should offer surgery followed by whole brain radiotherapy to patients who have a single or small number of brain metastases that could potentially be removed by surgery, a good performance status and who have no or well-controlled other metastatic disease. Following the publication of the guidance, Mr John Winstanley, consultant surgeon at Royal Bolton Hospital and Guideline Development Group (GDG) chair, commented: “It is important that being diagnosed with advanced breast cancer is not seen as an immediate death sentence; it can be managed effectively, allowing patients to have a reasonable quality of life. This guideline pulls together the best ways to treat the cancer medically, helping relieve the symptoms and to support patients psychologically, emotionally and practically.” The NICE guidance on early breast cancer3 further recommends that minimal surgery, rather than lymph node clearance, should be performed to stage the axilla for patients with early invasive breast cancer and no evidence of lymph node involvement on ultrasound, or a negative ultrasound-guided needle biopsy. Sentinel lymph node biopsy (SLNB) is the preferred technique. The guidance also states that patients with early invasive breast cancer should have a baseline dual energy X-ray absorptiometry (DEXA) scan to assess bone mineral density if they are starting adjuvant aromatase inhibitor treatment, have treatment-induced menopause or are starting ovarian ablation/suppression therapy. Patients treated for breast cancer should also have an agreed, written care plan, which should be recorded by a named healthcare professional. A copy of this should be sent to the GP and a personal copy given to the patient. Another key recommendation of the guidance was that clinicians should discuss immediate breast reconstruction with all patients who are being advised to have a mastectomy and should offer this except where significant comorbidity or (the need for) adjuvant therapy may preclude this as an option.

Breast reconstruction

However, although access to breast reconstruction surgery has improved, a number of reports have indicated that there is room for improvement. According to the second report from the National Mastectomy and Breast Reconstruction Audit, 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. Nevertheless, the proportion of women offered immediate reconstruction varies significantly by region and questions arise in relation to how the option is communicated. The proportion of women who accepted the offer of immediate reconstruction varies from 17% in one cancer network to 62% in another. The audit also found: • 21% of women who had a mastectomy (15,479) had immediate reconstruction; just under half of women who had a mastectomy (48%) were offered the procedure. • The rate of immediate reconstruction across England’s 30 cancer networks varied from 9% to 43%, with most networks reporting a rate of between 14% and 2%. The rate of offer of immediate reconstruction also varied. However, there is no strong correlation between the two rates. • In most cases, the reason clinicians gave for not offering immediate reconstruction was that the patients were deemed inappropriate for surgery due to clinical, health or lifestyle problems, or where there was a perceived need for adjuvant therapy, such as chemotherapy or radiotherapy. However in five of the 30 networks the reason stated was “the lack of a local or timely reconstructive service” for more than 30% of patients. The report pointed out that patients should have access to the full range of reconstructive options at the time of mastectomy. There are four main types of reconstruction: • The insertion of a tissue expander or fixed volume implant. • The insertion of an expander or implant placed with additional coverage from a pedicle flap from the back or abdomen. • The use of a pedicle flap on its own. • The use of a free flap from a distant donor site. The most common type of procedure for women undergoing immediate reconstruction was an implant or tissue expander based reconstruction (38%). For women undergoing delayed reconstruction, the most common type was free flap reconstruction (33%). This may reflect difficulties in access to a specialist reconstructive team while meeting the target of starting definitive treatment within 31 days of decision to treat. The audit also found that the time from decision to treat to first definitive surgical treatment varied between Cancer Networks. The proportion of women treated within 31 days varied from 76% to 94% for women having mastectomy only, and from 28% to 84% for women having mastectomy with immediate reconstruction. This suggests that current waiting time targets may be too rigid and do not allow women sufficient time in which to consider reconstructive options. Poorer levels of performance may also reflect variable resources and capacity at breast units in England. Recommendations include: • NHS Trusts and independent hospitals should review the way in which they offer reconstruction, to ensure barriers to women accepting the offer are minimised. • Cancer networks should also improve local access by ensuring adequate service provision to meet the increasing demand. • Cancer networks should ensure women are able to access all appropriate reconstructive options within current waiting times, even if not locally. Robin Burgess, chief executive of the Healthcare Quality Improvement Partnership, commented: “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.”