Transcript BASO 1999-2000 - Cancer screening

NHSBSP Surgical QA Data
for the Year of Screening
1 April 2000 to 31 March 2001
Dr Gill Lawrence and
Professor David George
on behalf of the
BASO Breast Group
West Midlands Cancer Intelligence Unit
Acknowledgements

The BASO Breast Audit Group
•
•
•
•
•
•
Mr Hugh Bishop
Mr James Bristol
Ms Olive Kearins
Dr Gill Lawrence
Mr Fergus Neilson
Mrs Julietta Patnick
•
•
•
•
•
Mr Paul Sauvern
Dr Matthew Wallis
Dr Jackie Walton
Mrs Margot Wheaton
Miss Emma Wheeler
would like to extend their thanks to the following
individuals and groups for their contributions to
the 2000/01 BASO Breast Audit
West Midlands Cancer Intelligence Unit
Acknowledgements




Surgical QA Co-ordinators
Breast Screening QA Co-ordinators
Regional QA Directors
BASO
• Mrs Veronica Hall


Newcastle QA Reference Centre
West Midlands Cancer Intelligence Unit
• Mrs Diane Edwards
• Dr Cheryl Livings

Government Actuary Department
• Mr Graham Lamberti
West Midlands Cancer Intelligence Unit
Details of
the regions
and countries
in the UK that
submitted data
to the 2000/01
BASO breast
audit
West Midlands Cancer Intelligence Unit
Women included in the
BASO audit
year
No.
women
screened
No.
cancers
detected
1996/97
1,340,175
7,410
1997/98
1,419,287
8,232
1998/99* 1,308,751
8,028
1999/00
1,550,285
9,797
2000/01
1,535,019
10,079
Total
7,153,517
43,546
* data from Scotland not available
West Midlands Cancer Intelligence Unit
In 2000/2001
• 79% invasive
• 1% micro-invasive
• 19% non-invasive
• 54 cancers (1%)
had unknown status
Pre-operative diagnosis
X
West Midlands Cancer Intelligence Unit
Pre-operative diagnosis rates
Minimum Standard > 70%
Target > 90%
year
Preoperative
diagnosis
rate
Regions
achieving
minimum
std
Regions
achieving
target
1996/97
63%
25%
0%
1997/98
71%
68%
0%
1998/99*
81%
100%
7% (1)
1999/00
85%
100%
10% (1)
2000/01
87%
100%
15% (2)
* data from Scotland not available
West Midlands Cancer Intelligence Unit
Pre-operative diagnosis rates for
invasive and non-invasive cancers
100
T a r g e t s ta n d a r d 9 0 %
Pre-operative diagnosis rate
90
80
70
60
M i n i m u m s ta n d a r d 7 0 %
50
40
For invasive cancers
10/13 regions meet the
90% target
30
20
10
In va s i ve
West Midlands Cancer Intelligence Unit
N o n - i n va s i ve
Scotland
N Ireland
Wales
North West
W Midlands
South West
S East W
S East E
London
Eastern
Trent
Y orkshire
Northern
0
Pre-operative diagnosis rates for
individual screening units
U n ite d K in g d o m 8 7 %
100
Pre-operative diagnosis rate
90
80
70
60
Only 2 units fail to
meet the minimum
standard
50
40
30
20
10
West Midlands Cancer Intelligence Unit
91
86
81
76
71
66
61
56
51
46
41
36
31
26
21
16
11
6
1
0
What would happen if all the
C4/B4 diagnoses were C5/B5?
100
Pre-operative diagnosis rate
95
90
85
80
75
70
65
C 5 /B 5 o r C 4 /B 4 h i g h e s t
West Midlands Cancer Intelligence Unit
P r e - o p e r a ti ve d i a g n o s i s r a te
91
86
81
76
71
66
61
56
51
46
41
36
31
26
21
16
11
6
1
60
Pre-operative diagnosis
52% MOB
technique
C4/B4
Pre-operative diagnosis rate (%)
100
T a r g e t s ta n d a r d 9 0 %
U n i te d K i n g d o m 8 7 %
90
80
70
60
M i n i m u m s ta n d a r d 7 0 %
16% MOB
no pre-operative
procedure
50
40
30
20
10
C 5 o n ly
West Midlands Cancer Intelligence Unit
C5 & B5
B 5 o n ly
Scotland
N Ireland
Wales
North West
W Midlands
South West
S East W
S East E
London
Eastern
Trent
Y orkshire
Northern
0
100
90
80
Selective use of
core biopsy with
micro-calcification?
70
60
50
40
30
20
10
B 5 A ( N o n - i n va s i ve )
West Midlands Cancer Intelligence Unit
B 5 B ( In va s i ve )
B 5 C (n o t a s s e s s a b le ) o r u n k n o w n
Scotland
N Ireland
Wales
North West
W Midlands
South West
S East W
S East E
London
Eastern
Trent
Y orkshire
0
Northern
Malignancy type at B5 core biopsy (%)
Invasive status at pre-operative
core biopsy
Open biopsies
West Midlands Cancer Intelligence Unit
Open biopsy rate per 1000 women
screened
Benign and malignant open
biopsy rates
2.0
benign
1.8
malignant
1.6
1.4
1.2
1.0
0.8
0.6
0.4
0.2
0.0
1996/97
1997/98
1998/99*
Year
1999/00*
2000/01
* data from Scotland not available
West Midlands Cancer Intelligence Unit
100
90
High C4/B4
High C1/B1
80
70
60
50
40
30
20
10
C 1 /B 1
West Midlands Cancer Intelligence Unit
C 4 /B 4
Scotland
N Ireland
Wales
North West
W Midlands
South West
S East W
S East E
London
Eastern
Trent
Y orkshire
0
Northern
Highest pre-operative diagnosis result (%)
Highest pre-operative result for
malignant open biopsies
Lymph nodes
West Midlands Cancer Intelligence Unit
Lymph node status
Nodal status should be obtained for all invasive cancers
It is desirable to examine a minimum of 4 lymph nodes
year
% of invasive cancers % with
Number of % without
with known nodal
less than
invasive
nodal
status
4 nodes
cancers information
positive
negative examined
1996/97
5,860
19
26
74
10.6
1997/98
6,427
13
25
75
9.0
1998/99*
6,200
10
26
74
6.7
1999/00
7,675
7
25
75
5.5
2000/01
7,945
7
25
75
5.0
West Midlands Cancer Intelligence Unit
* data from Scotland and N Ireland not available
Nodal status unknown for invasive
cancers in individual screening units
60
55
Nodal s tatus unk now n (%)
50
26 -180
invasive cancers
45
40
35
30
25
1 0 u n its
20
no nodal
s ta tu s
15
U n i te d K i n g d o m 7 %
u n kn o w n
10
5
West Midlands Cancer Intelligence Unit
h
d
l
i
d
l
e
e
g
f
c
c
c
c
c
d
k
k
i
h
g
j
d
0
Regional variation in nodal status
determination in 2000/01
24
% invasive cancers
20
16
% nodal status unknown
% with <4 nodes examined
11-17% nodal
status unknown
8.4% with
<4 nodes
examined
12
8
West Midlands Cancer Intelligence Unit
UK
Scotland
N Ireland
Wales
North West
W Midlands
South West
S East W
S East E
London
Eastern
Trent
Yorkshire
0
Northern
4
Up to 7.5% of cancers may have had
inadequate nodal assessment
9 .0
8 .0
U n i te d K i n g d o m 5 .0 %
7 .0
6 .0
5 .0
4 .0
3 .0
2 .0
1 .0
0
N e g a ti ve ( u n k n o w n o r o th e r p r o c e d u r e )
West Midlands Cancer Intelligence Unit
N e g a ti ve ( s e n ti n e l p r o c e d u r e )
P o s i ti ve
Scotland
N Ireland
Wales
North West
W Midlands
South West
S East W
S East E
London
Eastern
Trent
Y orkshire
0 .0
Northern
Nodal status w here <4 nodes exam ined (%)
Nodal status of invasive cancers
diagnosed on the basis of <4 nodes
Nodal status where <4 nodes
examined for individual units
Nodal s tatus w he r e <4 node s e xam ine d (%)
36
34
32
30
22 - 87
invasive cancers
28
26
24
22
20
18
16
1 4 u n its
14
U n ite d K in g d o m 5 .0 %
no nodal
12
s ta tu s
10
on <4 nodes
8
6
4
2
N e g a tiv e ( u n k n o w n o r o th e r p r o c e d u r e )
West Midlands Cancer Intelligence Unit
N e g a tiv e ( s e n tin e l p r o c e d u r e )
Po s itiv e
91
86
81
76
71
66
61
56
51
46
41
36
31
26
21
16
11
6
1
0
Surgical caseload
Women should be treated by a
specialist breast surgeon
West Midlands Cancer Intelligence Unit
Number of surgeons treating less
than 10 screening cases a year
40
number of surgeons
35
9 low
caseload
surgeons
30
25
20
6 low
caseload
surgeons
15
10
5
No info
>30 cases
West Midlands Cancer Intelligence Unit
J oine r /Le a ve r
P a tie nt Choic e
None of the s e
Scotland
N Ireland
Wales
North West
W Midlands
South West
S East W
S East E
London
Eastern
Trent
Y orkshire
Northern
0
Type of surgical treatment
provided to non-invasive and
invasive breast cancers
West Midlands Cancer Intelligence Unit
Treatment for non-invasive and
micro-invasive cancers
100
90
Type of treatm ent (%)
80
70
60
50
40
highest %
conservation
surgery
30
20
10
C o n s e r va ti o n s u r g e r y
West Midlands Cancer Intelligence Unit
M a s te c to m y
N o s u rg e ry
U n kn o w n
Scotland
N Ireland
Wales
North West
W Midlands
South West
S East W
S East E
London
Eastern
Trent
Y orkshire
Northern
0
Non-invasive cancer nuclear grade
unknown for individual units
100
90
13 and 22
cancers
Grade unknow n (%)
80
70
60
12
cancers
50
40
30
U n i te d K i n g d o m 7 %
20
10
0
West Midlands Cancer Intelligence Unit
91
86
81
76
71
66
61
56
51
46
41
36
31
26
21
16
11
6
1
6 1 u n i ts n o g r a d e u n k n o w n
Non-invasive cancer size
unknown for individual units
*
100
Non-invasive size unknow n (%)
90
19
cancers
80
70
60
12
cancers
50
40
30
U n i te d K i n g d o m 1 2 %
20
10
3 2 u n i ts
West Midlands Cancer Intelligence Unit
h
* 1 cancer
l
j
a
i
c
d
j
d
j
l
j
k
b
i
c
c
h
g
g
a
d
n o s i ze u n k n o w n
e
0
Non-invasive cancers treated
with conservation surgery
no. non -invasive cancers
24
High grade multi-focal
High grade, unknown extent
Unknown grade, unknown extent
Multi-focal 30+mm
20
16
12
8
West Midlands Cancer Intelligence Unit
Scotland
N Ireland
Wales
North West
W Midlands
South West
S East W
S East E
London
Eastern
Trent
Yorkshire
0
Northern
4
Variation in mastectomy rates
with invasive tumour size
high %
mastectomy for
small tumours
low %
mastectomy for
larger tumours
100
90
Mastectom y rate (%)
80
70
60
50
40
30
20
10
1 5 -1 9 m m
2 0 -4 9 m m
50+m m
Scotland
N Ireland
Wales
North West
W Midlands
South West
S East E
London
Eastern
Trent
West Midlands Cancer Intelligence Unit
<15m m
S East W
high %
mastectomy for
small tumours
Y orkshire
Northern
0
Treatment of small cancers with
invasive diameter <15mm
Conservation surgery (%)
100
<15mm
15-19mm
20-49mm
50+mm whole size
80
19
60
16
10
21
40
1
1
20
0
Northern
West Midlands Cancer Intelligence Unit
Trent
Eastern
S East E
Final treatment for cancers with
2 or more operations
70
invasive
non-invasive
50
40
30
20
West Midlands Cancer Intelligence Unit
Scotland
N Ireland
Wales
North West
W Midlands
London
Eastern
Trent
Yorkshire
Northern
0
South West
10
S East W
low mastectomy
rate for non-invasive
tumours
S East E
Mastectomy rate (%)
60
low
mastectomy
rate for invasive
tumours
The patient journey
Which journeys were undertaken?
How long did it take to get there?
What combinations of treatments were given?
West Midlands Cancer Intelligence Unit
?
Cases included in the analysis
highest proportion
of cases included
Coding error
correct value 93%
- Wales excluded
from analyses
100
% cases included
80
60
40
West Midlands Cancer Intelligence Unit
Scotland
N Ireland
Wales
North West
W Midlands
South West
S East W
S East E
London
Eastern
Trent
Yorkshire
0
Northern
20
The most common patient
journeys
Total cancers detected between
1st April and 30th September 2000
5011
Cancers included in patient journey analysis
3147
Journeys
exclude
variations
in hormone
therapy
Surgery
Surgery
Surgery
Surgery
Surgery
Other
1033
(33%)
RT
CT
RT
CT
1521
(49%)
RT
CT*
77
(2%)
61
(2%)
382
(12%)
35
(1%)
West Midlands Cancer Intelligence Unit
* includes CT and RT started
on same day
Regional variations in the
High surgery
patient journey
High CT
only, low CT
100
90
Patient Journey (%)
80
70
60
50
40
30
20
10
A s s e s s to S u r g e r y o n ly
A s s e s s to S u r g e r y to R T
West Midlands Cancer Intelligence Unit
A s s e s s to S u r g e r y to C T to R T
Scotland
N Ireland
North West
W Midlands
South West
S East W
S East E
London
Eastern
Trent
Y orkshire
Northern
0
O th e r jo u r n e y
Treatment patterns for noninvasive and invasive cases
Non-invasive cases
100
100
% cases
60
-HT
Higher proportion
of invasive tumours
receive HT
+HT
60
40
40
20
20
0
0
S only S + RT S + CT Total
(+/-RT)
West Midlands Cancer Intelligence Unit
-HT
80
% cases
+HT
80
Invasive cases
S only S + RT S + CT Total
(+/-RT)
Times to first treatment and from
first treatment to adjuvant therapy
West Midlands Cancer Intelligence Unit
Time to first surgery
N Ireland 95%
S East E 39%
100
90
Cumulative %
80
70
60
50
40
30
20
10
0
0
30
60
90
120
Da ys fr om a s s e s s m e nt to fir s t s ur ge r y
4941 cases
West Midlands Cancer Intelligence Unit
Time from surgery to radiotherapy
Wales and Trent 85%
Yorkshire 44%
100
90
Cum ulative %
80
70
60
50
40
30
20
10
0
0
30
60
90
120
Da ys fr om fir s t s ur ge r y to r a diothe r a py
Cases with no S or CT before RT excluded
West Midlands Cancer Intelligence Unit
1931 cases
Time from surgery to chemotherapy
London 52%
South West 4%
100
90
Cum ulative %
80
70
60
London, S East E
>10% started CT
on same day as or
before surgery
50
40
30
20
10
0
0
30
60
90
120
Da ys fr om fir s t s ur ge r y to c he m othe r a py
Cases with no S or RT before CT excluded
West Midlands Cancer Intelligence Unit
603 cases
Questions about treatment
?
Does ER status influence the use of
hormone treatment?
?
Does nodal status influence the use of adjuvant
radiotherapy in women having conservative surgery?
?
Does nodal status influence the use of adjuvant
radiotherapy in women having mastectomy?
?
Does nodal status influence the use of adjuvant
chemotherapy?
?
Do women with node negative, ER negative tumours
receive adjuvant chemotherapy?
West Midlands Cancer Intelligence Unit
Proportion of cases with
unknown ER status
45%
unknown
50
Only 11%
unknown
Unknow n ER status (%)
45
40
U n i te d K i n g d o m 2 2 %
35
30
25
20
15
10
5
West Midlands Cancer Intelligence Unit
Scotland
N Ireland
North West
W Midlands
South West
S East W
S East E
London
Eastern
Trent
Y orkshire
Northern
0
Invasive and non-invasive cases
with unknown ER status
39%100
invasive cases
ER status unknown
non-invasive
90
Unknown ER status (%)
80
invasive
Non-invasive 60%
70
60
50
40
Invasive 12%
30
20
West Midlands Cancer Intelligence Unit
Scotland
N Ireland
North West
W Midlands
South West
S East W
London
Eastern
Trent
Yorkshire
Northern
0
S East E
10
45%
unknown
ER status
Hormone therapy invasive tumours
ER +ve
100
63% ER-ve
given HT
ER -ve
Hormonal treatment (%)
90
ER+ve 92%
80
70
12% or more
not given HT
60
50
ER-ve 31%
40
30
20
West Midlands Cancer Intelligence Unit
Scotland
N Ireland
North West
W Midlands
South West
S East W
London
Eastern
Trent
Yorkshire
Northern
0
S East E
10
Conservatively treated invasive
cancers with +ve nodes receiving RT
100
90
Radiotherapy (%)
80
70
U n i te d K i n g d o m 9 3 %
60
50
40
58% all cancers
treated with
surgery alone
30
20
10
West Midlands Cancer Intelligence Unit
Scotland
N Ireland
North West
W Midlands
South West
S East W
S East E
London
Eastern
Trent
Y orkshire
Northern
0
Effect of nodal status on conservatively
treated invasive cancers receiving RT
node +ve 93%
100
90
Radiotherapy (%)
80
node -ve 85%
70
60
Nodal status has little
influence on treatment choice
50
40
30
20
node +ve
node -ve
West Midlands Cancer Intelligence Unit
Scotland
N Ireland
North Wes t
W Midlands
South Wes t
S East W
London
Eastern
Trent
Yorkshire
Northern
0
S East E
10
Cancers with +ve nodes treated
with mastectomy and radiotherapy
100
100%
given RT
U n i te d K i n g d o m 6 8 %
90
Radiotherapy (%)
80
70
60
50
40
Only 50%
given RT
30
20
10
West Midlands Cancer Intelligence Unit
Scotland
N Ireland
North West
W Midlands
South West
S East W
S East E
London
Eastern
Trent
Y orkshire
Northern
0
Effect of nodal status on invasive
cancers treated with mastectomy
receiving RT
100
node +ve
90
node -ve
node +ve 68%
80
45%
given RT
Radiotherapy (%)
70
60
Nodal status does
influence treatment choice
50
40
30
node -ve 16%
20
10
Scotland
N Ireland
North West
W Midlands
South West
S East W
London
Eastern
Trent
Yorkshire
Northern
West Midlands Cancer Intelligence Unit
S East E
0
0
Effect of nodal status on
treatment with chemotherapy
80
70
node +ve
less than 50%
given CT
node -ve
node +ve 61%
Chemotherapy (% )
60
50
32% all cancers
treated with
chemotherapy
40
30
20
node -ve 9%
West Midlands Cancer Intelligence Unit
Scotland
N Ireland
North Wes t
W Midlands
SoUth West
S East W
London
Eastern
Trent
Yorkshire
Northern
0
S East E
10
ER -ve, node -ve tumours
treated with chemotherapy
80
70
Chemotherapy (%)
60
In 1992-96
15% tumours
were grade III
17%
given CT
75%
given CT
United Kingdom 40%
50
40
30
20
West Midlands Cancer Intelligence Unit
Scotland
N Ireland
North West
W Midlands
SoUth West
S East W
London
Eastern
Trent
Yorkshire
Northern
0
S East E
10
Survival analyses
for 19,023
screen-detected
cancers diagnosed
1992-96
West Midlands Cancer Intelligence Unit
Data quality
Parameter 1992/93 1993/94 1994/95 1995/96
% Unknown
Size
7
5
4
1992-96
2
5
(9% North West)
% Unknown
Grade
21
19
15
11
17
(28% S East E)
% Unknown
Nodal Status
42
38
31
28
35
(63% North West)
West Midlands Cancer Intelligence Unit
Unregistered cases
16
QARC
looked up
dates of death
at HAs
Non-r e gis te r e d cas e s (%)
14
12
10
8
6
4
2
0
0
Ex c lu d e d u n r e g is te r e d c a s e s
West Midlands Cancer Intelligence Unit
In c lu d e d u n r e g is te r e d c a s e s
N Ireland
Wales
North West
W Midlands
South West
S East W
S East E
London
Eastern
Trent
Y orkshire
Northern
0
Variations in relative survival invasive breast cancer
5yr UK 94.1%
8yr UK 90.9%
100
90
Relative Survival %
80
70
60
50
40
30
20
5 year survival
8 year survival
10
West Midlands Cancer Intelligence Unit
N Ireland
Wales
North West
W Midlands
South West
S East W
S East E
London
Eastern
Trent
Yorkshire
Northern
0
Factors affecting 5 and 8 year
relative survival
Overall survival
1-9mm
10-19mm
5y and 8y
very similar
20-49mm
50+mm
Size Unknown
Grade I
Grade II
Grade III
Grade Unknown
Nodes -ve
Nodes +ve
Nodes Unknown
60
5 year survival
65
70
8 year survival
West Midlands Cancer Intelligence Unit
75
80
85
Relative survival %
90
95
100
Variation in survival with NPI
% population surviving
100
98.4%
90
80
86.2%
70
NPI
Gp 1 <3.4
Gp 2 3.4-5.4
Gp 3 >5.4
Total
60
50
40
0
1
No.
5,645
4,107
638
10,390
2
3
46.2%
54.6%
4
5
6
Survival time in years
NPI Group 1
West Midlands Cancer Intelligence Unit
NPI Group 2
NPI Group 3
7
8
Variation in survival with screening
history in West Midlands 1992-96
100
% population surviving
90.2%
90
80
69.3%
Screening History
SD
1,786
I
1,170
DBI
497
LP
73
NA
580
Total
4,106
70
60
50
0
1
62.9%
51.6%
2
3
4
5
6
7
Survival time in years
SD
West Midlands Cancer Intelligence Unit
I
DBI
LP
NA
8
West Midlands Cancer Intelligence Unit