Guideline adherence for early breast cancer before and after introduction of the sentinel node biopsy

Abstract

This population-based study aimed to analyse variations in surgical treatment and guideline compliance with respect to the application of radiotherapy and axillary lymph node dissection (ALND), for early breast cancer, before and after the sentinel node biopsy (SNB) introduction. The study included 13 532 consecutive surgically treated stage I -IIIA breast cancer patients diagnosed in 1989 -2002. Hospitals showed large variation in breast-conserving surgery (BCS) rates, ranging between 27 and 72% for T1 and 14 and 42% for T2 tumours. In multivariate analysis marked inter-hospital and time-dependent variation in the BCS rate remained after correction for case-mix. The guideline adherence was markedly lower for elderly patients. In 25.2% of the patients aged X75 years either ALND or radiotherapy were omitted. The proportion of patients with no ALND after an SNB increased from 1.8% in 1999 to 37.8% in 2002. However, in 2002 also 12.2% of the patients with a positive SNB did not have an ALND. Guideline compliance for BCS, with respect to radiotherapy and ALND, fell since the SNB introduction, from 96.1% before 2000 to 91.4% in 2002 (Po0.001). Noncompliance may however reflect patient-tailored medicine, as for elderly patients with small, radically resected primary tumours. The considerable variation in BCS-rates is more consistent with variations in surgeon preferences than patient's choice.

Adherence to Recommended Treatments for Early Invasive Breast Cancer: Decisions of Women Attending Surgeons in the Breast Cancer Audit of Australia and New Zealand

“…In general, older women were more likely to decline a treatment recommendation, which is consistent with non-adherence results from other studies (Truong et al, 2004;Schaapveld et al, 2005;Wockel et al, 2010 a ;Lebau et al, 2011;Weggelaar et al, 2011). Declining treatment recommendations was most apparent for radiotherapy.…”

“…Patient adherence to recommended breast cancer treatments varies widely with treatment setting, but commonly poorer adherence has been associated with older age, low income status, some ethnic sub-groups, and lower educational status (Hebert-Croteau et al, 1999;Li et al, 2000;Truong et al, 2004;Schaapveld et al, 2005;Gilligan et al, 2007;Hershman et al, 2011;Lebeau et al, 2011;Weggelaar et al, 2011). Often adherence has been lower for adjuvant chemotherapies and radiotherapy than surgical interventions (Wockel et al, 2010a).…”

Improvement of best practice in early breast cancer: actionable surgeon and hospital factors

“…Previous studies have attempted to explain practice variations in breast cancer care, evaluating both patient and disease characteristics. However, even after adjusting for case-mix, inter-hospital variation was still large [8,[11][12][13]. Although various authors have suggested the importance of the role of the surgeon [12,14,15] and the hospital [9,[16][17][18], their relative impact on the unexplained variation in surgical treatment of breast cancer patients is unclear and actionable factors for improving quality of care are lacking.…”

“…This study used data from the population-based Regional Cancer Registry (RCR) and from the oncological 'visitatie' of hospitals in the CCCN region. The data collection by the RCR is described elsewhere [12]. The multidisciplinary 'visitatie' evaluates quality of cancer care delivered in Dutch hospitals, according to a framework for quality of oncological care [19][20][21].…”

Patterns of care in Dutch postmenopausal patients with hormone-sensitive early breast cancer participating in the Tamoxifen Exemestane Adjuvant Multinational (TEAM) trial

“…For The Netherlands, this has been reported in studies with respect to breast-conserving surgery (BCS), sentinel lymph node procedure (SLNP) and chemotherapy [9][10][11]. So far, data on adherence to the NABON guideline are scarce and were generated from retrospective population-based studies carried out in a particular CCCR, while no data are available on the variation in patterns of breast cancer care between all different CCCRs.…”