Last Update: 17/02/2012 17:01
The
National Breast Cancer Audit is continually performing research
into trends in the diagnosis and management of breast cancer in
Australia and New Zealand. This research has resulted in a number
of publications in internationally recognised journals. Below are
summaries of a selection of recent publications generated by the
audit team. For further information see our publications page.
Survival information on National
Breast Cancer Audit patients
Access to breast care
nurses: A National Breast Cancer Audit survey of breast
surgeons
How surgical treatment for
women with early breast cancer can change with age
Are males with early breast
cancer treated differently from females with early breast cancer in
Australia and New Zealand?
Trends in surgical treatment of
younger patients with breast cancer in Australia and New
Zealand
Have clinical guidelines for
breast cancer treatment changed practice?
The use of
multidisciplinary care teams by breast surgeons in Australia and
New Zealand
Management of ductal carcinoma in
situ in Australia and New Zealand
Survival information on National
Breast Cancer Audit patients
The National Breast Cancer Audit (NBCA) of the Royal
Australasian College of Surgeons has been collecting information
from surgeons on the treatment of their patients who were diagnosed
with breast cancer since 1998. This data is used to assess surgeon
performance, as well as for research into early breast cancer
treatment in Australia and New Zealand.
As the data does not include information on how many patients
survive, researchers decided to link the audit database to the
central database of deaths at the Australian Institute of Health
and Welfare, the National Death Index (NDI). However, the NBCA data
only uses the first three letters of the patient's name and the
date of birth, to protect privacy. Researchers wanted to make sure
that linked NDI data would refer to the same patient and not
another person with a similar name.
A pilot study was conducted in South Australia (SA), in which
data on a small number of patients recorded in the NBCA and also
the SA Cancer Registry were linked to the SA death records. The two
linkages gave similar results.
The remaining Australian cases in the NBCA database were then
linked with the NDI data, and the results were compared with
reported survival rates of patients with breast cancer in New South
Wales and the United States of America. The survival rates were
similar in all three databases.
This study showed that the data of the NBCA and the NDI can be
linked successfully. The NBCA data can now be used to consider how
factors like age, screening and differences in treatment affect the
survival of Australian breast cancer patients.
Roder, D, Wang, J, Zorbas, H, Kollias, J, & Maddern, G.
Survival from breast cancers managed by surgeons participating in
the National Breast Cancer Audit of the Royal Australasian College
of Surgeons. ANZ Journal of Surgery, 2010 Nov; 80 (11):776-780.
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Access to breast care
nurses: A National Breast Cancer Audit survey of breast
surgeons
Breast care nurses (BCNs) provide continuity of care for
patients being treated for cancer by various professionals, and
make sure that patients are well informed about both the disease
and their treatment. This level of support can improve the physical
and psychological outcomes for early breast cancer patients. The
National Breast and Ovarian Cancer Centre recommends that a BCN
should be one of the 6 core members of a multi-disciplinary care
team. Guidelines recommend that the patient sees the BCN before
surgery.
A 2006 survey found that the majority of Australian and New
Zealand surgeons involved in the National Breast Cancer Audit have
access to a BCN either in or outside their practice, although there
were differences in access. Public practices were more likely to
have direct access to a BCN than private, while surgeons in rural
areas found access difficult overall. Direct access to a BCN was
also more frequent in New Zealand than in Australia.
Patient interactions with a BCN were most common directly after
diagnosis. In a third of practices surveyed, patients met the BCN a
second time (usually after surgery), although no private rural
patients had access to a BCN more than once.
This study shows that overall, practices have adequate access to
a BCN, however BCN availability needs to improve in private and
rural practices. Resources are needed to address this inequality
and conduct research into the issues affecting the availability of
BCNs in Australia and New Zealand. The McGrath Foundation intends
to address the lack of access to BCNs in rural Australia.
Marsh C, Wang J, Kollias J, Boult M, Rice J & Maddern G.
Disparities in access to breast care nurses for breast surgeons: a
National Breast Cancer Audit survey. Breast, 2010
Apr;19(2):142-6.
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How surgical treatment for
women with early breast cancer can change with age
Researchers looked at whether the age of women with early breast
cancer affected the surgical treatment they had in Australia and
New Zealand between 1999 and 2006. They found that a woman was more
likely to have some treatments if she was in a given age group.
How a surgeon takes a sample of breast tissue
To find out if a woman has breast cancer, a surgeon takes a
sample of a lump in the breast by either:
- inserting a fine needle into the breast (the most common
treatment)
- core biopsy - the surgeon inserts a large needle through a cut
in the skin (more common in women 50-70 years)
- open biopsy - the surgeon takes tissue out through a cut in the
skin (most common in women under 40 years).
Number of operations
- Women under 40 years were more likely to have larger,
high-grade cancers which had spread to the lymph nodes. One in four
patients needed more than one operation.
- Women over 70 were less likely to need more than one
operation.
Breast conserving surgery or mastectomy
- Among patients with early breast cancer who were likely to have
similar health outcomes, given their condition and symptoms,
younger women were more likely to have breast conserving surgery.
More research is needed to check that these women have adequate
surgery and follow up.
- Women over 70 years with breast cancers that could be treated
with breast conserving surgery were more likely to have a
mastectomy.
Wang J, Kollias J, Boult M, Babidge W, Zorbas HN, Roder D,
Maddern G. Patterns of surgical treatment for women with breast
cancer in relation to age. Breast J. 2010
Jan;16(1):60-5.
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Are
males with early breast cancer treated differently from females
with early breast cancer in Australia and New Zealand?
Breast cancer is much rarer in males than females. Guidelines
for treating early breast cancer have focussed on the treatment of
female patients. This study found that males with early breast
cancer were treated differently from females, despite the lack of
male-specific guidelines. A total of 151 cases of male breast
cancer diagnosed and treated between 2000 and 2008 were compared
with the treatment of female patients whose cancer was detected by
their symptoms.
Results of the study showed that males were more likely to have
only one tumour. These tumours were more likely to be oestrogen or
progesterone receptor-positive and tended to be smaller than
tumours in females.
Most males underwent mastectomy (86%), while only 3% of males
had breast conserving surgery (compared with around half of female
patients). A significant proportion of males did not have surgery
(11%), which was twice the proportion of females, although no males
in the study had refused surgery.
Males were also less likely to have a sentinel node biopsy than
symptomatic female patients, and were less likely to undergo
radiotherapy, chemotherapy or hormonal therapy for oestrogen
receptor positive tumours. The low level of radiotherapy may be
related to the high proportion of male patients who have
mastectomy, although males were also less likely to receive
chemotherapy than female mastectomy patients.
Wang, J., Kollias, J., Marsh, C. & Maddern, G. Are males
with early breast cancer treated differently from females with
early breast cancer in Australia and New Zealand? Breast,
2009; 18 378-381.
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Trends in
surgical treatment of younger patients with breast cancer in
Australia and New Zealand
Researchers looked at trends in the surgical treatment of young
women with invasive cancer using information from the National
Breast Cancer Audit (NBCA). The rate of breast conserving treatment
for women aged 40 years or younger in Australia and New Zealand
stayed at around 53% between 1999 and 2006. This suggests that the
use of breast conserving treatment in younger patients has
stabilised, although more research is needed to check that this is
the best level of care for patients.
Patients were less likely to have breast conserving treatment
than mastectomy if the cancer was:
- multifocal (i.e. more than one cancer in the breast)
- >30 mm in diameter
- centrally located (i.e. behind the nipple)
- high grade (i.e. cancer cells were more likely to spread)
- also present in a lymph node
- EIC positive (had an extensive intraductal component, that is,
an extensive area of ductal carcinoma in situ beyond the invasive
cancer).
Studies have shown that the presence of these factors means the
cancer is more likely to recur at the site if the tumour is removed
through breast conserving surgery. By providing mastectomy in those
cases, surgeons contributing to the NBCA are making decisions based
on the best available evidence for managing breast cancer in young
women.
Wang J, Boult M, Tyson S, Babidge W, Zorbas H, Kollias J, Roder
D, Maddern G. Trends in surgical treatment of younger breast cancer
patients in Australia and New Zealand. Australian and New
Zealand Journal of Surgery. 2008 Aug;78 (8):665-9.
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Have
clinical guidelines for breast cancer treatment changed
practice?
Clinical guidelines are developed using research data, or
evidence, to guide surgeons in the treatment of their patients. In
1995 clinical guidelines were developed on breast cancer treatment,
recommending that radiotherapy treatment should follow breast
conserving surgery (BCS). The Breast Section of the Royal
Australasian College of Surgeons would like at least 85% of these
patients to receive radiotherapy.
To see whether the guidelines led to a change in breast cancer
treatment practice, researchers looked at data submitted by
surgeons to the National Breast Cancer Audit (NBCA). In the decade
after the guidelines were introduced, the number of BCS patients
who did not receive radiotherapy dropped by half. By 2007 almost
90% of BCS patients received radiotherapy, more than expected by
the Breast Section. Patients were less likely to receive
radiotherapy after BCS if they were older (30% of patients over 70
years compared with 5-6 % of women under 70 years) or at low risk
(with smaller, less aggressive tumours and with no information
about the lymph gland status).
In conclusion, most breast surgeons are following the
recommendation for radiotherapy following BCS. For some patients
with good prognostic factors it may be reasonable to omit
radiotherapy. Large data collections like the NBCA can be used to
monitor whether clinical guidelines are changing practice.
J Wang, J. Kollias, C. Marsh, J. Chesson, M. Boult, W. Babidge
and G. Maddern, Monitoring recommendation uptake in breast cancer
treatment practice - experience from NBCA, poster presentation at
The National Forum on Safety and Quality in Health Care
29-31 Oct 2008 Adelaide.
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The use of
multidisciplinary care teams by breast surgeons in Australia and
New Zealand
All patients with early breast cancer should have access to care
from a range of disciplines, according to the National Health and
Medical Research Council (NHCRM). Multidisciplinary care (MDC)
teams should include surgeons, medical oncologists, radiation
oncologists, radiologists, pathologists, breast care nurses and
general practitioners, as recommended by the National Breast and
Ovarian Cancer Centre.
A survey sent to all breast surgeons in Australia and New
Zealand revealed that:
- 85% of surgeons were part of at least one fully established MDC
team.
- The six recommended disciplines were well-represented in most
teams, with general practitioners the most poorly represented.
- Most team meetings occurred after surgery when the pathology
results were obtained, to discuss treatment options.
- Most practices had established a communication framework;
however, patients were more likely to be discussed in a
multidisciplinary forum in public hospitals than private practice
(91% versus 83%), and meetings were more likely to be weekly.
- MDC teams were less common in rural areas, and weekly meetings
occurred rarely.
The results of this unique study indicate that breast surgeons
in Australia and New Zealand accept the importance of MDC in the
treatment of breast cancer patients. However, to ensure that all
patients have access to MDC, policymakers must address the
difficulties of rural practices in establishing multidisciplinary
forums. Surgeons in private practice also need to be encouraged to
conform to the standards reached by public service surgeons in this
area.
Marsh CJ, Boult M, Wang JX, Maddern GJ, Roder DM, Kollias J.
National Breast Cancer Audit: the use of multidisciplinary care
teams by breast surgeons in Australia and New Zealand. Med J
Aust. 2008 Apr 7;188(7):385-8.
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Management of ductal carcinoma in
situ in Australia and New Zealand
Ductal carcinoma in situ (DCIS) is the presence of abnormal
cells in the milk ducts and milk sacs of the breast; these cells
are not malignant and do not spread to the rest of the body. Up to
20% of diagnosed breast cancer cases are DCIS. The study looked at
whether patients with DCIS in Australia and New Zealand were
treated in accordance with the 2003 National Breast Cancer Centre
guidelines. The 3629 patients were enrolled in the National Breast
Cancer Audit by 274 surgeons between January 1998 and December
2004.
Overall, patients were treated according to the guidelines.
However, improvements could be made in the following areas:
- The use of radiation therapy for large and/or high grade
tumours was lower than recommended.
- 30% of patients had axillary interventions, which are not
recommended unless the tumour is invasive.
- More information is needed on the benefits of tamoxifen for
cases of DCIS.
A Cuccins-Hearn, M Boult, W Babidge, H Zorbas, E Villanueva, A
Evans, D Oliver, J Kollias, T Reeve, G Maddern, National Breast
Cancer Audit: Ductal Carcinoma In situ Management in Australia and
New Zealand, ANZ J. Surg. 2007; 77: 64-68.
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