National Breast Cancer Audit - Publications

Survival from breast cancers managed by surgeons participating in the National Breast Cancer Audit of the Royal Australasian College of Surgeons.

Roder D, Wang JX, Zorbas H, Kollias J, Maddern G.
ANZ J Surg. 2010 Nov;80(11):776-80.
Background: The National Breast Cancer Audit (NBCA) of the Royal Australasian College of Surgeons has collected data on early breast cancer since 1998. In this project, deaths were traced by linkage of NBCA patient identifiers (first three digits of surname and date of birth) with the National Death Index that covers all deaths in Australia. Methods: Death data were traced to 31 December 2007. Invasive cancers diagnosed in 1998-2005 were included in survival analyses to allow enough follow-up for assessment. Survivals were compared with survivals for similar stages recorded by the New South Wales (NSW) Cancer Registry and USA Surveillance Epidemiology and End Results (SEER) programme. Survivals were analysed by conventional clinical risk factors to see if expected differences presented. Results: The 5-year survival from breast cancer of 93% for NBCA cases was the same as the SEER figure for local and regional cases combined in 1996-2004. The NBCA figure for localized cases was 97%, which was the same as for NSW. Node-positive NBCA cancers had a 5-year survival of 89%, which was slightly higher than the corresponding 86% for NSW, which may reflect exclusion from the NBCA of some cases with a poorer prognosis, including those with positive fixed nodes. As expected, lower survivals presented for older cases and those with conventional clinical risk factors. Conclusions: These survivals are credible both overall and by clinical risk factor. Opportunities present to use these data for survival monitoring and to investigate survival by socio-demographic characteristic, treatment protocol, case volume and provider characteristics.

PubMed reference: PMID: 20969682

Disparities in access to breast care nurses for breast surgeons: a National Breast Cancer Audit survey.

Marsh C, Wang J, Kollias J, Boult M, Rice J, Maddern G.
Breast. 2010 Apr;19(2):142-6.
The involvement of a breast care nurse (BCN) in breast cancer treatment can improve the physical and psychological outcomes and provide the continuity of care and better information about the disease and treatment process. This survey examined the current status of BCNs access to determine the extent and how BCNs were accessed by breast surgeons across Australia and New Zealand in different geographical settings or health service sectors. The survey was disseminated in December 2006. Response rate was 91%. The results show that the majority of Australian and New Zealand breast surgeons either work with a BCN in their practice or can access a BCN outside their practice. Patients are more likely to have access to a BCN immediately after diagnosis while around a third of practices have access to a BCN more than once, usually "after diagnosis" and "after surgery". More public practices have direct access to a BCN than private practices, particularly in the metropolitan and regional areas while access to BCN is poor in rural public and private practices. The difference in overall access, either in the practice or external access (Yes or No but can access a BCN), to a BCN between public and private practices is smaller. Access to a BCN was best in metropolitan public practices and worst in rural private practices with one quarter rural private practices had no access to a BCN and no rural patients can access a BCN more than once in private practice. The results of this survey demonstrated some evidence of disparity in access to a BCN which needs to be reduced through more attention and/or extra resources in this area.

PubMed reference: PMID: 20172728

Patterns of surgical treatment for women with breast cancer in relation to age.

Wang J, Kollias J, Boult M, Babidge W, Zorbas HN, Roder D, Maddern G.
Breast J. 2010 Jan;16(1):60-5.
Although treatment recommendations have been advocated for all women with early breast cancer regardless of age, it is generally accepted that different treatments are preferred based on the age of the patient. The aim of this study was to assess the pattern of breast cancer surgery after adjusting for other major prognostic factors in relation to patient age. Data on cancer characteristics and surgical procedures in 31,298 patients with early breast cancer reported to the National Breast Cancer Audit between 1999 and 2006 were used for the study. There was a close association between age and surgical treatment pattern after adjusting for other prognostic factors, including tumor size, histologic grade, number of tumors, lymph node positivity, lymphovascular invasion (LVI), and extensive intraduct component. Breast Conserving Surgery (BCS) was highest among women aged <or=40 years (OR = 1.140; 95% CI: 1.004-1.293) compared to women aged 51-70 years (reference group). BCS was lowest in women aged >70 years (OR = 0.498, 95% CI: 0.455-0.545). Significantly more women aged <or=50 years underwent more than one operation for breast conservation (20.4-24.8%) compared with women aged >50 years (11.4-17.0%). Women aged >70 years were more likely to receive no surgical treatment, 3.5% versus 1.0-1.3% in all other age groups (<or=40, 41-50 51-70 years). There is an association between patient age and the type of breast cancer surgery for women in Australia and New Zealand. Women age <or=40 years are more likely to undergo BCS despite having adverse histologic features and have more than one procedure to achieve breast conservation. Older women (>70 years) more commonly undergo mastectomy and are more likely to receive no surgical treatment.

PubMed reference: PMID: 19889171

Are males with early breast cancer treated differently from females with early breast cancer in Australia and New Zealand?

Wang J, Kollias J, Marsh C, Maddern G.
Breast. 2009 Dec;18(6):378-81.
Breast cancer in males is much rare than in females so in practice, male breast cancer treatment is likely to follow the guidelines developed for female breast cancer patients. The objective of this study is to compare the characteristics and treatment pattern of male breast cancer patients with comparable subgroups of female breast cancer patients using data submitted to the National Breast Cancer Audit. This is a retrospective analysis of 151 male breast cancers diagnosed and treated between 2000 and 2008. Most of the male early breast cancer cases in this group were symptomatic ones in men aged >50 years with one invasive tumour. There was a similar proportion of lymph node positive cancer among males and females, although male breast cancer was more likely to be unifocal (P=0.007) and oestrogen receptor positive (P=0.001). Male breast cancer patients almost always underwent mastectomy and a significant proportion of them (11%) received no surgical treatment. There were no differences in axillary surgery although males were more likely to undergo a level 2 axillary surgery and less likely to have sentinel node biopsy. Male patients were significantly less likely to undergo radiotherapy, chemotherapy or hormonal therapy for oestrogen receptor positive tumours. Conclusion: While the female oriented treatment guidelines are available, male patients with early breast cancer received different surgical and adjuvant treatment from comparable females.

PubMed reference: PMID: 19850477

Trends in surgical treatment of younger patients with breast cancer in Australia and New Zealand.

Wang J, Boult M, Tyson S, Babidge W, Zorbas H, Kollias J, Roder D, Maddern G.
ANZ J Surg. 2008 Aug;78(8):665-9.
Background: The optimal surgical treatment of early breast cancer in young women is not fully determined, while past reports indicate a trend to the increased use of breast-conserving surgery (BCS). This study aims to assess the trend in Australia and New Zealand of BCS use between 1999 and 2006 and to determine pathological factors associated with it. Methods: Data on cancer characteristics and surgical procedures in younger patients with early breast cancer reported to the National Breast Cancer Audit have been analysed. Results: There was little change in the rate of BCS over the last 7 years with an overall rate of 53%. The main factors associated with the use of BCS are low histological grade, absence of extensive intraductal carcinoma (EIC), negative lymph node involvement, unifocal tumour and small tumour size. Conclusion: Between 1999 and 2006, the use of BCS for early breast cancer treatment in younger women was stable. These results show that surgeons contributing data to the National Breast Cancer Audit appear to use pathological factors that are known to increase the risk of local recurrence after BCS, in selecting mastectomy for younger women.

PubMed Reference: PMID: 18796024

Commentary: how surgical audits can be used to promote the update of surgical evidence.

Wang J, Boult M, Roder D, Babidge W, Kollias J, Maddern G.
ANZ J Surg. 2008 Jun; 78(6):437-8.
Evidence-based medicine (EBM) is an important advance in health care. The Australian Safety and Efficacy Register of New Interventional Procedures - Surgical (ASERNIP-S), the Royal Australasian College of Surgeons, has been at the forefront of promoting EBM in surgery by developing systematic reviews and managing surgical audits. In EBM, uptake of evidence is just as important as establishing the evidence. The prospective, long-term data collection of surgical audits on treatment processes and outcomes often have a high patient and surgeon coverage and make them extremely valuable as a tool for assessing the uptake of evidence. Surgical audits can be used: (i) to assess practice trends and the impact of systematic reviews or clinical guidelines on treatment practice, (ii) to identify the disparities in the uptake of evidence, and (iii) to promote further research on how to bridge evidence-practice gaps and to overcoming possible barriers for the evidence uptake. The information gathered through the audit data assessment on evidence-uptake can be used to improve evidence dissemination and identify possible barriers to the uptake of evidence.

PubMed reference: PMID: 18522561

National Breast Cancer Audit: the use of multidisciplinary care teams by breast surgeons in Australia and New Zealand.

Marsh CJ, Boult M, Wang JX, Maddern GJ, Roder DM, Kollias J.
Med J Aust. 2008 Apr 7;188(7):385-8. Comment in:Med J Aust. 2008 Apr 7;188(7):380-1.
Objective: To explore the involvement of members of the Royal Australasian College of Surgeons (RACS) Section of Breast Surgery in Australia and New Zealand in multidisciplinary care (MDC) teams. Design and setting: Questionnaire sent to all full members of the RACS Section of Breast Surgery in December 2006. PARTICIPANTS: 239 of 262 active full members of the RACS Section of Breast Surgery (response rate, 91.2%). Main outcome measures: Surgeons' use of, and the composition and functioning of, MDC teams in public and private practice, and in metropolitan, regional and rural settings. Results: 85% of responding surgeons reported participating in at least one fully established MDC team. Public-sector teams were operationally more consistent and functional than private teams, and rural teams were less well developed than those in metropolitan and regional centres. The six core disciplines recommended by the National Breast Cancer Centre appear to be well represented in most teams. Patients and their general practitioners were not considered to be part of the treatment team by surgeons. Conclusions: MDC is supported by most breast surgeons, but there are deficits in rural areas, and in the private sector relative to the public sector.

PubMed Reference: PMID: 18393739

Clinical audits: why and for whom.

Boult M, Maddern GJ.
ANZ J Surg. 2007 Jul;77(7):572-8.
Every surgical activity poses some element of risk to the public and should include a quality control initiative. Surgical audit is one strategy used to maintain and/or improve standards in surgical care. The Royal Australasian College of Surgeons is committed to ensuring best practice in surgical care and strongly endorses the use of audits to achieve this. This review provides an overview of clinical audit and its role in surgical practice.

PubMed Reference: PMID: 17610696

National Breast Cancer Audit: ductal carcinoma in situ management in Australia and New Zealand.

Cuncins-Hearn A, Boult M, Babidge W, Zorbas H, Villanueva E, Evans A, Oliver D, Kollias J, Reeve T, Maddern G.
ANZ J Surg. 2007 Jan-Feb;77(1-2):64-8.
Background: Ductal carcinoma in situ (DCIS) is a significant issue in Australia and New Zealand with rising incidence because of the implementation of mammographic screening. Current information on its natural history is unable to accurately predict progression to invasive cancer. In 2003, the National Breast Cancer Centre in Australia published recommendations for DCIS. In Australia and New Zealand, the National Breast Cancer Audit collects information on DCIS cases. This article will examine these recommendations and provide information from the audit on current DCIS management. Methods: Three thousand six hundred and twenty-nine cases of DCIS were entered by 274 breast surgeons between January 1998 and December 2004. Data items in the National Breast Cancer Audit database that were covered in the National Breast Cancer Centre recommendations were reviewed. Information was available on the following: diagnostic biopsy rates for all cases and mammographically positive cases and rates of breast conserving surgery (BCS), clear margins following BCS, postoperative radiotherapy following BCS for groups at high risk of recurrence as well as axillary procedures and tamoxifen prescription. Results: Close adherence was found in diagnostic biopsy, BCS and clear margin rates. Some high-risk groups received radiotherapy, although women with 'close' margins did not in 33% of cases. Axillary procedures were conducted in 23% of cases and most (81%) patients were not prescribed tamoxifen. Conclusion: There was predominantly close adherence to recommendations with three possible areas of improvement: fewer axillary procedures, an appraisal of radiotherapy practice following BCS and more investigation into tamoxifen prescription practices for DCIS.

PubMed reference: PMID: 17295824

National breast cancer audit: overview of invasive breast cancer management.

Cuncins-Hearn AV, Boult M, Babidge W, Zorbas H, Villanueva E, Evans A, Oliver D, Kollias J, Reeve T, Maddern G.
ANZ J Surg. 2006 Aug;76(8):745-50.
Background: The National Breast Cancer Audit is an initiative of the Breast Section of the Royal Australasian College of Surgeons collecting surgical information in early breast cancer. It is managed in conjunction with the Australian Safety and Efficacy Register of New Interventional Procedures - Surgical. An overview of results for invasive breast cancer from January 1999 until December 2004 is presented to provide preliminary data for participating surgeons. Methods: Invasive breast cancer cases were retrieved from the National Breast Cancer Audit database for the 274 participating breast surgeons in Australia and New Zealand. Data for a variety of clinical parameters were analysed to provide an overview of the diagnostic, histological, surgical and adjuvant therapy management issues. Results: There were 25,026 cases of invasive breast cancer. Annual percentages of mammographically detected cancers from 1999 to 2004 did not differ significantly. Breast-conserving surgery rates also remained stable at 60%. Margins were involved in 5% of patients; an additional 9% had final margins of less than 1 mm. Radiotherapy followed breast-conserving surgery in most cases (86%). Patients undergoing mastectomy with large tumours (>5 cm) underwent radiotherapy in 71% of cases. When at least four lymph nodes were positive, radiotherapy followed mastectomy in the majority (75%) of cases. The most frequently carried out axillary procedure was a level 2 dissection. Chemotherapy was received by 78% of oestrogen receptor negative, axillary node positive, postmenopausal patients. Tamoxifen was used in the majority (83%) of oestrogen receptor positive cases. Conclusion: Surgeons contributing their invasive breast cancer data show a high quality of treatment. Some further improvement may be possibly related to excision margins and tamoxifen prescription for oestrogen receptor negative cancers. Chemotherapy prescription might also warrant further investigation.

PubMed reference: PMID: 16916399

National Breast Cancer Audit: establishing a web-based data system.

Boult M, Cuncins-Hearn A, Tyson S, Kollias J, Babidge W, Maddern G.
ANZ J Surg. 2005 Oct;75(10):844-7.
Background: An audit of surgical treatment of early breast cancer was introduced nationally in 1999. In August 2002, the Australian Safety and Efficacy Register of New Interventional Procedures - Surgical, under the auspices of the Royal Australasian College of Surgeons, assumed responsibility for managing this audit. This article provides an update of audit activities, now known formally as the National Breast Cancer Audit (NBCA), including a description of the new governance structure and the development of a secure online surgical audit system. Methods: Major changes have taken place in the design and governance of the NBCA during the last two years. Two committees have been established to oversee the audit. A clinical advisory committee comprises experts from a number of fields including breast surgery, oncology, government, and from peak breast cancer and consumer bodies. A technical advisory committee oversees many of the technical issues that have arisen with the development of an online data entry system. The online system of data entry was developed and launched to surgeons in May 2004. Results: There are now 28,000 cases of primary breast surgery in the audit. Around 250 surgeons are currently participating, an increase of over 50 surgeons since May 2004. Surgeons can review their data using the online system and compare their own results by generating reports which graph their own results against national aggregate data. Conclusions: There has been a significant increase in the volume of data received since the launch of the secure online system. The governing committees are working towards creating a clinical audit which will provide an improved data entry system and better reporting for all participating surgeons. The NBCA can also serve as a template on which to base other surgical audits.

PubMed reference: PMID: 16176221

Collation of Australasian data regarding breast cancer.

Malycha P.
ANZ J Surg. 2001 May;71(5):265. Comment on: ANZ J Surg. 2001 May;71(5):266-70.

PubMed reference: PMID: 11374472

National breast surgery audit.

Malycha P, Tyson S.
ANZ J Surg. 2000 Dec;70(12):834-6.
Background: Surgical audit is routinely conducted throughout the surgical community in order to examine practice in a peer-review environment. A national audit for breast cancer surgery has been implemented in Australia and New Zealand. It aims to standardize the way in which surgical activities are recorded. The present paper describes the development and implementation of the audit project. Methods: An audit kit including instruction manual, data dictionary and choice of two data collection instruments (paper or database) were distributed among participants. Surgeons record their patients prospectively, submit data to central office and provide feedback. Results: Information on 3000 breast cancer patients has been collected within the first 6 months. Conclusion: The project has been successfully implemented and is continuing to develop. Many surgeons have incorporated the patient record forms in their routine case management activities. Comments and other submissions have been reviewed and changes incorporated into the second and subsequent releases of the kit.

PubMed reference: PMID: 11167568