1st August 2014, Volume 127 Number 1399

Valerie Davey, Gavin Harris, Birgit Dijkstra, Melissa James, Bridget Robinson

Breast cancer remains the most common cancer in New Zealand women, affected 2791 women in 2010 (27.5% of all female cancer registrations) and was the second leading cause of female cancer deaths,1 641 of 4082 (15.7%).

In Canterbury, 436 patients were recorded on the Christchurch Breast Cancer Patient Register (CBCR) in 2012 comprising 14.5% of all New Zealand breast cancer registrations (n=3003).2

The Faster Cancer Treatment (FCT) indicators,3 developed by the Ministry of Health (MOH), stipulate all patients referred to a hospital with a high suspicion of cancer should have their first specialist assessment (FSA) within 14 days (indicator 2) and receive their first cancer treatment (surgery or oncology therapy) within 62 days (indicator 1).

Once a cancer diagnosis is confirmed, patients should receive their first cancer treatment (or other management) within 31 days of decision-to-treat (indicator 3).4

Developed in late 2013 as part of the FCT programme, Standards of Service Provision for Patients with Breast Cancer in New Zealand5 (Tumour Standards) ensure uniformity and timeliness of care for all patients diagnosed with breast cancer from time of referral to the patients’ first cancer treatment through to adjuvant therapy (see Figure 1).

 

Figure 1. Standards of service provision for patients with breast cancer in New Zealand (published December 2013)

 

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The aim of this study is to determine whether standards on Timely Access to Services(Standards 2.1 to 2.9) were attained at Christchurch Hospital in 2012, and to discover factors which impeded patient pathways, and which would need to be addressed in order to meet the standards.

Because services provided by the private sector are not under the jurisdiction of the FCT or Tumour Standards, the management of private patients after diagnosis are not included.

Methods

All patients referred in Christchurch with a new diagnosis of breast cancer between 1 January 2012 and 31 December 2012 were studied.

All cases had been entered onto the Christchurch Breast Cancer Register (CBCR), which since 2009 has recorded comprehensive details about diagnosis, clinical history, pathology, treatment and subsequent outcome. Complete ascertainment of all breast cancer cases is confirmed by cross-referencing with the New Zealand Cancer Registry.

Patients referred to CPH with benign disease are not captured by CBCR. Data for the patients diagnosed in 2012 at Christchurch Hospital was extracted from the CBCR database by the Register data coordinator. Additional data was collated from the CDHB electronic hospital record system, BreastScreen Aotearoa (BSA) and the Oncology Service Mosaiq databases.

In this review, all referrals were re-categorised as high suspicion of breast cancer instead of subgroups of low, moderate or high suspicion due to the small numbers of low (n=4) to moderate (n=2) patients, and included patients with in-situ or invasive disease. Consent was required during 2012 for patients to be added to the Register, a condition waived subsequently.

The dates of referral, first specialist assessment (FSA), discussion in multi-disciplinary meeting (MDM), referral and all treatments were supplemented by information from the CDHB patient management system. Time from referral to first specialist assessment (FSA), and then to first treatment, to MDM, to first oncology assessment, and from decision to treat until treatment were calculated in elapsed days (7 day week).

Time points based on FCT indicators and the breast cancer Tumour Standards were used to evaluate the timeliness of all aspects of breast cancer management provided at Christchurch Hospital. These were expressed as medians, range and as percent of applicable standard achieved.

The following definitions are used for this review: The date of receiving referral is the date a patient is waitlisted for FSA. However, the date of waitlist for surgery is used for patients who require further surgery following an excision biopsy proven cancer or BSA patients referred directly for surgery. The date of FSA is the date of the first specialist appointment with any breast clinician (surgeon/oncologist).

The date of decision-to-treat is the clinic date a patient gives consent for treatment (surgery or therapy). The first surgical intervention (FSI) comprises the initial breast or axillary surgery. Final surgery is the last operation whether this is the same as the FSI or additional surgery such as re-excision of margins or completion mastectomy.

In Christchurch, the majority of patients with suspected breast cancer follow a simple pathway whereby a general practitioner (GP) or BSA send a referral to the Department of General Surgery (GNSU) at Christchurch Hospital. Where a GP has deemed a patient at high suspicion of breast cancer, following the Canterbury Health Pathways guidance, and imaging and biopsy have confirmed cancer, referral to GNSU is triggered.

Patients are assessed by a breast surgeon prior or following a breast cancer diagnosis, and proceed to breast surgery. However, patients who require a mastectomy with breast reconstruction and referral to a plastic surgeon, or who require further imaging and/or biopsies as part of their diagnostic workup, follow a complex pathway often with a delay to surgery.

During 2012, all cases at CPH were considered in the weekly MDM attended by breast surgeons, reconstructive surgeons, medical and radiation oncologists, breast nurses, a radiologist and an anatomical pathologist.

The breast nurses helped action decisions made at the MDM. Patients who receive all their care through Canterbury BreastCare (private breast clinic) are included in the CBCR but are not analysed for time to assessment and treatment.

Results

The demographics of 436 patients (including one male) from Canterbury, newly diagnosed with their first breast cancer during 2012, are shown below in Table 1. Overall, a quarter of patients (25.7%, n=112) were aged under 50 and 74.3% (n=324) aged 50 and over.

Ninety percent of patients were of European descent (n=395), 4.6% Maori (n=20), 0.4% Pacific peoples (n=2) and 4.4% from other ethnicity (n=19) such as Asian. Less than half of patients were diagnosed via the screening programme (45.2%, n=197) with 54.8% (n=239) symptomatic patients referred by their GP or other sources.

Breast cancer was early stage I or II in 72.9% patients (n=318), with 11.7% (n=51) Stage III, and 2.8% (n=12) Stage IV. Twelve percent (11.9%, n=52) had ductal carcinoma in-situ without any invasive component and 0.7% (n=3) had Paget’s disease of the nipple or lobular carcinoma in situ. One-third of patients (33.9%, n=148) were treated in the private sector and the remainder at Christchurch Hospital.

Sixty-one patients were ineligible for CBCR due to the following reasons: 2 patients declined to join the Register; 1 received their breast cancer surgery outside Canterbury; 57 patients had a previous history of breast cancer prior to 2009 (public=36, private= 21), and 1 breast cancer was diagnosed at post-mortem.

 

Table 1. Demographics of breast cancer patients diagnosed during 2012 who receive treatment in Canterbury

Variable

Private sector

Public sector

Total

Percentage

Number of patients

148

288

436

100%

Age (years)

Age <50

Age ≥50

 

47

101

 

65

223

 

112

324

 

25.7%

74.3%

Ethnicity

European

Maori

Pacific People

Other

 

138

1

0

9

 

257

19

2

10

 

395

20

2

19

 

90.6%

4.6%

0.4%

4.4%

Presentation

BreastScreen Aotearoa

GP referrals

 

84

64

 

113

175

 

197

239

 

45.2%

54.8%

Prognostic staging

Stage I–II

Stage III

Stage IV

 

106

16

1

 

212

35

11

 

318

51

12

 

72.9%

11.7%

2.8%

Ductal carcinoma in-situ (DCIS only)

24

28

52

11.9%

Lobular carcinoma in-situ (LCIS)/Paget's

1

2

3

0.7%

 

A total of 288 breast cancer patients diagnosed in 2012 were treated at CPH. Of these, 171 (59.4%) patients were referred to GNSU by their GP, 113 (39.6%) were referred by BSA and 4 (1.4%) were referred directly to a medical oncologist with metastatic breast cancer at diagnosis.

The 171 patients referred to GNSU by their GP included symptomatic patients with high suspicion of breast cancer (89.5%, n=153); patients with low (2.3%, n=4) to moderate (1.2%, n=2) suspicion of breast cancer; patients assessed at Canterbury BreastCare before being directed to CPH for treatment (6.4%, n=11) and 1 (0.6%) elderly patient who was unfit for surgery whose GP sought treatment advice (no FSA). The first breast cancer treatment for women referred from their GP or from BSA to Christchurch Hospital is shown in Tables 2 and 3 respectively.

 

Table 2. First breast cancer treatment for GP referrals to Christchurch Hospital in 2012

Department of initial referral

First breast cancer treatment

Number of patients

Percentage

GNSU

(Department of General Surgery)

Surgery

124

70.9%

Excision biopsy of breast lesions for Low to high suspicion of breast cancer

9

5.1%

No primary surgery - Endocrine therapy prescribed by surgeon

11

6.3%

Preoperative Endocrine therapy prescribed followed by delayed surgery

2

1.1%

Endocrine therapy prescribed by GP as advised by GNSU (no FSA)

1

0.6%

GNSU – Re-direct to Oncology

Neoadjuvant chemotherapy

14

8.0%

GNSU – Re-direct to Oncology

Neoadjuvant therapy prescribed by oncologist (no primary surgery)

7

4.0%

GNSU – Re-direct to Oncology

Palliative oncology therapy* (extensive metastatic disease at presentation)

3

1.7%

Medical Oncology

Endocrine therapy (extensive metastatic disease at presentation)

4

2.3%

Total number of patients

 

175

100%

* Palliative therapy include radiation (n=2) & chemotherapy (n=1).

 

Table 3. First breast cancer treatment for referrals to Christchurch Hospital from BreastScreen Aotearoa (national breast screening programme) in 2012

Department of initial referral

First breast cancer treatment

Number of patients

Percentage

GNSU

(Department of General Surgery)

Surgery via simple pathway (waitlist for surgery without FSA at GNSU)

39

34.5%

Surgery via complex pathway (further diagnostic workup & FSA required)

65

57.5%

Surgery* (additional surgery for incidental malignancy from excision biopsy for suspicious lesion)

7

6.2%

GNSU – Redirect to Oncology

Neoadjuvant chemotherapy

1

0.9%

Radiation Oncology

Postoperative radiation therapy (incidental malignancy from BSA excision biopsy for suspicious lesion)

1

0.9%

Total number of patients

 

113

100%

* May include re-excision, mastectomy &/or axillary surgery.

First specialist appointment (FSA)—Overall 240 patients were referred and had their FSA at Christchurch Hospital (CPH) at either GNSU (n=236) or Oncology Services (n=4). The remaining 48 patients had their FSA at BSA or Canterbury BreastCare.

Sixty-one percent of patients (60.8%, n=146) had their FSA within 14 days of a referral for high suspicion of breast cancer, compared with ≥90% required by Standard 2.1. The median time from waitlist to surgical FSA was 11 days (range 0–224). Overall 18.8% (n=45) required further imaging with or without biopsies prior to FSA. This did not have any significant impact on FSA times despite the need for additional workup as 80% (n=36) of patients were seen within 14 days with a median time from waitlist to FSA of 7 days (range 0–101). Six patients were referred by their GP for low to moderate suspicion of cancer but excision biopsy showed malignancy (range 5–224).

First breast cancer treatment: overall (surgery & neoadjuvant therapy)—The first cancer treatment received by the 288 patients referred to CPH in 2012 was surgery for the majority (84.7%, n=244), radiation therapy for 1 BSA patient following an excision biopsy which showed malignancy, neoadjuvant chemotherapy for 16, endocrine therapy for 24, and radiation therapy for 3.

In accordance with Standard 2.5, 88.5% (n=253) of 286 patients with a confirmed diagnosis of breast cancer received their first cancer treatment at CPH within 31 days of decision-to-treat.

Overall, 87.1% (n=250) of patients referred urgently with a suspicion of breast cancer received their first cancer treatment within 62 days in compliance with Standard 2.4. Table 4 shows the range of days from referral to first cancer treatment.

 

Table 4. Number of days from referral to first breast cancer treatment at Christchurch Hospital (Standard 2.5/FCT indicator 3)

Variable

Referral to first breast cancer treatment (within 62 days)

Decision-to-treat to first breast cancer treatment (31 days)

Number of patients

287 a

286 a & b

Range (days)

3–197

0–118

Median (days)

28

14

Average (days)

35.1

16.8

Number of patients who met Standard

250

253

% met standards

87.1%

88.5%

Met standard ≥80%

Yes

Yes

a One patient received her first breast cancer treatment elsewhere (decision-to-treat date unavailable).

b One patient prescribed hormonal therapy by the GP (decision-to-treat date unavailable.

 


First cancer treatment: surgery—see Figure 2.

 

Figure 2. First surgical intervention (FSI)

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Overall referrals to GNSU (GP & BSA referrals)—85% (84.7%, n=244) of 288 patients diagnosed with breast cancer underwent surgery as their first cancer treatment.

Of 240 women who were referred urgently (waitlisted) to GNSU, (54.5%, n=133) were GP referrals with the remaining patients referred by BSA. More than 80% of patients received their FSI within 62 days of referral (87.3%, n=213) and within 31 days of decision-to-treat (86.1%, n=210) with median 16 days (range 2-118).

Table 5 shows the timeline from GP or BSA referral to FSI for those who had surgery as their first breast cancer treatment.

 

Table 5. First cancer treatment (surgery)—time to first surgical intervention (FSI) for GP & BSA referrals

Variable

GP Referrals

BSA Referrals

 

Decision to Treat to FSI

Referral to FSI

Decision to Treat to FSI

Referral to FSI

Number of patients

133

133

111

111

Range (days)

2 - 118

3 - 123

2 - 92

3 - 110

Median (days)

15

32

17

22

Average (days)

17.3

39.1

21.1

27.1

Number of patients who met standards

121

111

89

103

% Met standards

91%

83.5%

80.2%

92.8%

Met standard ≥80%

Yes

(Standard 2.5)

Yes

(Standard 2.4)

Yes

(Standard 2.5)

Yes

(Standard 2.4)

 

GP referrals—Overall, 83.5% of patients referred by their GP to GNSU received their FSI within 62 days, median 32 days (Table 5). Eighteen percent of patients in both GP referred (n=24) and BSA referred (n=20) groups required further diagnostic workup prior to surgery. A smaller number of patients (6%, n=8) were referred for breast reconstruction with one patient who decided against it. One patient (0.8%) had surgery delayed due to a haematoma post biopsy.

Two patients (1.5%) were diagnosed with other cancer at the same time as their breast cancer diagnosis. Both required chemotherapy for the other cancer before commencing treatment for breast cancer. Ninety-one percent (n=118) of GP referred patients received their FSI within 31 days of decision-to-treat (median 15 days).

BSA referrals—BSA referred 113 patients (39.2% of 288 patients) with screen detected breast cancers to CPH for treatment. Under the BSA programme, patients are usually assessed by a breast surgeon prior to a core biopsy of abnormalities seen on imaging, and then seen again with the histology results (FSA).

The majority of screening patients (98.2%, n=111) received surgery as their first breast cancer treatment. Nearly a third of BSA patients (34.5%, n=39) were on the simple pathway (direct referral for surgery without FSA at CPH) whereas more than half the patients (57.5%, n=65) required further diagnostic workup or FSA at GNSU before definitive decision-to-treat.

One screening patient (0.9%) was referred on for neoadjuvant chemotherapy. Amongst eight patients referred for further treatment following an excision biopsy proven breast cancer diagnosis, seven (6.2%) required further surgery whereas one (0.9%) did not require further surgery and was referred on for radiation therapy.

Eighty percent of BSA-referred patients (n=89) received their FSI within 31 days of decision-to-treat (Table 2), a median of 17 days (range 2–92) while 92.8% (n=103) were treated within 62 days of referral (median 22 days).

In all, 18% (n=20) required further diagnostic workup pre-operatively; 11.7% (n=13) were seen by a Plastic surgeon for consideration of immediate breast reconstruction however two patients declined reconstruction; 3.6% (n=4) developed a haematoma post biopsy which obscured hook wire localisation thus delaying surgery.

Breast reconstruction patients—Overall, 21 patients (8.6%) were referred to a plastic surgeon for consideration of immediate breast reconstruction and/or contralateral breast reduction, of whom 81% (n=17) accepted reconstructive surgery. The median time from referral to FSI for this group (n=20, one patient not waitlisted) was 46 days (range 15–110), and 70% (n=14) were treated within 62 days. The median time from decision-to-treat to FSI for all patients referred for reconstructive surgery was 13 days (range 3–51). Fewer GP-referred patients were referred for immediate breast reconstruction (38.1%, n=8).

Adjuvant oncology referrals & therapies—Postoperatively, 81.6% (n=199) patients were referred to Oncology Services for consideration of adjuvant therapy, 5.7% (n=14) were commenced on endocrine therapy by their surgeon (no referral to Oncology), 1 patient (0.4%) commenced chemotherapy at a different centre, while the remaining patients (12.3%, n=30) were not recommended any adjuvant therapy by the MDM team.

Of those referred to Oncology, chemotherapy was not recommended for 13 patients (6.5%) and they were referred on to Radiation Oncology for consideration of radiation therapy. Based on the total number of Oncology referrals (n=212), including patients re-referred for radiation, the median time from being wait-listed in Oncology to FSA was 11 days, (range 2–72 days).

More than two-thirds of patients (n=148, 69.8%) were seen within 14 days which is marginally better than the performance level for GNSU (62%) however this is well short of the required Standard of ≥90%. Overall 86.9% (n=174) of referred patients accepted adjuvant oncology therapy. Figure 3 gives an overview of adjuvant oncology therapies while Table 6 shows the various pathways patients undergo with calculated days between events.

Figure 3. Flow chart of adjuvant oncology therapies

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*Note: One patient commenced adjuvant chemotherapy elsewhere & is excluded; 13 patients, for whom chemotherapy was not used, were referred to Radiation Oncology.


First adjuvant therapy: chemotherapy—Chemotherapy was the first adjuvant therapy in 63 women. One patient returned to her home country for adjuvant therapies and is excluded. Forty patients (63.5%) commenced chemotherapy within 6 weeks (42 days) of final breast cancer surgery (≥90% for Standard 2.6) with a median of 38 days (range 13–127), while 88.9% (n=56) commenced chemotherapy within 42 days of the MDM. The majority of patients (96.8%, n=61) commenced chemotherapy within 31 days of decision-to-treat (median 13 days, range 2-35) in accordance with Standard 2.5.

A quarter of patients (25.4%, n=16) required additional surgery following FSI. This meant that nearly half of patients started chemotherapy within 42 days of their FSI (47.6% n=30) with a median of 44 days (range 21–212).

Types of additional surgery included: re-excision of close margins in five, completion mastectomy in two, axillary clearance in seven (two with further excision), and completion mastectomy with immediate reconstruction in two.

One patient, diagnosed with extensive in situ disease, had to lose weight before she was suitable for completion mastectomy with immediate breast reconstruction, but final histology showed invasive carcinoma, prompting referral for adjuvant chemotherapy (FSI to adjuvant chemotherapy = 212 days).

Other reasons for delays in starting adjuvant chemotherapy include CT staging before consideration of therapy (17.5%, n=13); postoperative infection or haematoma (9.5%, n=6); late or missed referral from GNSU (3.2%, n=2) and patient’s prearranged trip (1.6%, n=1).

Forty-four (69.8%) of the patients who received chemotherapy went on to have radiation therapy, with 72.7% (n=32) commencing radiation within 42 days of their last chemotherapy dose (median 37.5 days, range 11-198). However only 27.2% (n=12) of patients met the good practice point of starting radiation within a month (31 days) of their last chemotherapy dose.

Two patients waited an extended time before commencing radiation: one who underwent a completion mastectomy because of previous close margins (84 days) and one who stopped chemotherapy earlier than expected.

First adjuvant therapy: radiation—Radiation therapy was the first adjuvant therapy for 93 patients, of whom 57% (n=53) had their Radiation Oncology FSA within 14 days of referral (Standard 2.8) with a median of 14 days (range 3–30). Ninety-one percent of patients (n=85) commenced radiotherapy within 31 days of decision-to-treat (FCT indicator 3) with a median of 22 days (range 14–70).

The median time from final surgery to a patient’s treatment plan being discussed at the MDM was 13 days (range -18 to 30), from MDM to Radiation Oncology referral one day (range -11 to 103), including 13 patients referred prior to the MDM. Fewer than half of patients (46.2%, n=43) commenced radiotherapy within 6 weeks of MDM with a median of 43 days (range 24–192).

The median number of days from final surgery to first radiation treatment was 55 (range 25–205). Sixteen women (17.2%) had required additional surgery. Using the FSI, the median number of days from FSI to first radiation treatment was 59 (range 35–205).

In 2012, patients were required to commence radiation therapy within 8 weeks (56 days) postoperatively. At the time of review in July 2013, this Standard had been amended to 6 weeks (42 days).

Based on the previous standard, 53 (57%) of patients had radiation therapy within 8 weeks of their final surgery. However only 15% (n=14) of patients met the 2013 standards requirement of 6 weeks. More than a quarter of patients commenced endocrine therapy upon completion of radiation therapy (28%, n=26), at a median 24 days (range 0–70) from last radiation.

Reasons for delays starting radiation therapy varied. Thirteenpatients (14%) had seen a medical oncologist to consider chemotherapy which was decided against, nine (9.7%) had delays with the surgery team, three had postoperative wound infection or haematoma, three patients (3.2%) went on pre-arranged trips and one needed treatment for a synchronous non-breast cancer (delay of 205 days).

There are no required performance levels for radiation therapy Standards 2.8 and 2.9. Since the cumulative median was 28 days from final surgery to MDM, MDM to referral and referral to FSA, this left 2 weeks from FSA to first radiation treatment date. Furthermore, patients need CT planning following their FSA or decision-to-treat, before treatment can start. The times from FSA to CT planning to start of radiation therapy were not audited.

First adjuvant therapy: endocrine—Endocrine therapy was the first adjuvant therapy for 31 patients, who fell into two groups. The first group of patients were prescribed endocrine therapy by an oncologist (n=17), and 76.5% of them (n=13) had endocrine therapy prescribed within 42 days following final surgery (median 37 days, range 7–118).

The other group of 14 women were not referred to an oncologist and were prescribed endocrine therapy by their surgeon with 64.3% (n=9) starting therapy within 42 days of final surgery (median 23 days, range 10–71). The two extended delays were due to staff error (107 days) and oncology treatment for another cancer (118 days). The date of starting endocrine therapy was determined from the review of clinical records.

First cancer treatment: neoadjuvant chemotherapy—5% (n=15) of all breast cancer referrals to Christchurch Hospital were referred on directly for neoadjuvant chemotherapy with 46.7% (n=7) presenting with inflammatory breast cancer. Overall, 87.5% (n=14) received their first breast cancer treatment within 62 days of referral and 66.7% (n=10) had their FSA within 14 days of referral. One patient had her Oncology FSA and first few cycles of neoadjuvant chemotherapy at another hospital.

The patient with the longest delay to chemotherapy of 92 days, had extensive metastatic disease, described in the following section on inflammatory breast cancer. The majority of patients (93.3%, n=14) underwent CT scan staging prior to therapy, except for one with early breast cancer who elected to have neoadjuvant chemotherapy. Upon completion of neoadjuvant chemotherapy, all 15 patients had surgery, 86.7% (n=13) of them within 31 days of decision-to-treat.

Following surgery, all patients went on to have radiation therapy at a median of 58 days after surgery (range 33–109), with delays for chemotherapy (n=1); late referral (n=1, 76 days); postoperative wound infections (n=3, range 84–95 days) and personal reasons (n=1). Fewer than half of patients (46.7%, n=7) were prescribed endocrine therapy within a median of 5 days (range 0-33) following the completion of radiation therapy.

Inflammatory breast cancer—All 7 patients (100%) with inflammatory breast cancer had their FSA with a medical oncologist within 14 days of referral from GNSU meeting ≥90% for Standard 2.7 (median 7 days, range 1–10).

The median time from initial GP referral to neoadjuvant chemotherapy was 27 days (range 21–92), with 6 patients starting chemotherapy within 62 days of initial GP referral. The remaining patient had metastatic disease, and underwent palliative radiation as her first treatment 56 days after referral. Although 1 patient underwent egg harvesting before start of chemotherapy, she commenced treatment less than 4 weeks following her GP referral (27 days). It is unclear if the referral source for Standard 2.7 refers to one from a GP or from the surgeon.

Other referrals to oncology services—Overall, 39 patients were referred to the Oncology Service, but did not receive the treatment requested to be considered. A third of patients were referred to a medical oncologist, and chemotherapy was not started and they were then referred on for radiation therapy (33.3%, n=13). The remaining 26 did not commence any oncology therapy. Two patients had extended delays from final surgery to their oncology FSA (146 and 91 days) because appropriate referrals were not made following the recommendations from the MDM, whereas two patients were delayed while their surgical specimens were sent for an overseas opinion.

Discussion

The aim of this study is to determine whether standards on Timely Access to Services (Standards 2.1 to 2.9) were attained at CPH in 2012, and to discover factors which impeded patient pathways, and which would need to be addressed in order to meet the standards. The overall performance levels against the Standards have been brought together in Table 7.

Only some of the 2013 Tumour Standards were achieved as demonstrated by this review. Overall, breast cancer patients treated at Christchurch Hospital received their first breast cancer treatment within a timely manner thus meeting Standards 2.4 and 2.5 (Table 7).

Furthermore, patients with inflammatory breast cancer were assessed within 14 days (Standard 2.7). However a third of patients did not receive their first specialist assessment within 14 days (Standard 2.1) nor was adjuvant systemic therapy commenced within 42 days of surgery (Standard 2.6).


Table 7. Overall performance levels & standards

Standard

Description

Recommended performance level

% Met standard

Standard met

2.1 (FCT indicator 2)

FSA within 14 days of referral

≥ 90%

60.8%

No

2.4 (FCT indicator 1)

First breast cancer treatment within 62 days of referral

≥ 80%

87.1%

Yes

2.5 (FCT indicator 3)

First breast cancer treatment within 31 days of decision-to-treat

≥ 80%

88.5%

Yes

2.6

Adjuvant systemic treatment within 42 days of surgery

≥ 90%

63.5%

No

2.7

Medical Oncology FSA within 14 days of referral for patients with inflammatory breast cancer

≥ 90%

100%

Yes

2.8

Radiation Oncology FSA within 14 days of referral (no chemo)

None

57%

N.A.

2.9

Radiation therapy started within 42 days of referral

None

15%

N.A.

Note: FCT = Faster Cancer Treatment; FSA = First specialist assessment.

 

In March 2014, after this audit was commenced, MOH updated the FCT indicators and their associated data definitions8 for retrospective reporting to MOH by district health boards. The 14 day indicator (FCT 2) was no longer used due to inconsistencies in FSA reporting, whilst the two remaining FCT indicators (1 and 3) were renamed the 62-day and 31-day indicators respectively,9 both of which were met in 2012. In addition, screening patients are to be excluded from the 62-day indicator (FCT 1) as they are asymptomatic and BSA have existing monitoring mechanisms.

Using the CBCR database was both a strength and limitation for this audit, since benign breast diseases are not included. Although private treatment is not required to meet the same standards, it would have provided a more complete picture to have been able to include performance for all patients. Several changes have already occurred since 2012.

Canterbury HealthPathways now mandate that GPs do not perform a FNA on a suspicious lump prior to imaging as this causes unnecessary delay of breast cancer treatment, and a new triage system was introduced at GNSU to reduce the time from referral to FSA. In May 2014, CDHB added new codes (such as screened referrals and reasons for delay of FSA or treatment) to their patient management system for more accurate reporting for FCT indicators.

The multidisciplinary care in Standard 5.1 recommends that the care of every patient with breast cancer is discussed at the MDM5 and clearly documented. The Breast MDM is held on Mondays, which in 2012 coincided with five public holidays. When final histology was not available, discussion is delayed 1 week or 2 weeks if a holiday, delaying referrals to Oncology Services.

Treatment and FSAs may also be delayed by staff leave, particularly over Christmas or New Year. Holding the MDM twice in the week could be considered. The details of the pathology report are fundamental for planning any further surgery, such as re-excision, and also referrals for adjuvant therapy. Staffing resources for Anatomical Pathology therefore must be sufficient for timely reporting of breast cancer samples.

Fifty-seven percent of patients started radiation therapy within 8 weeks of final breast cancer surgery, which was the Standard in 2012, while 15% would have met the 2013 Tumour Standards. Barriers to timely treatment were multifactorial, including late referrals, re-directed referrals from Medical Oncology after the decision was not to use chemotherapy, and the need for CT planning following decision-to-treat before starting radiation therapy.

One solution is for patients to be referred to Oncology Services following their Surgical FSA once their breast cancer diagnosis is confirmed, especially if clinical staging suggests they are likely to require adjuvant therapies.

Discussion could then start about adjuvant treatment and it can be expedited once histology is available. This practice is common in the private sector. However this may lead to an additional or wasted appointment since the decision-to-treat depends on the final histology, and extend the time between referral to oncology and first treatment.

Additional breast cancer surgery, which was needed in 25% of patients starting adjuvant chemotherapy, also delayed its commencement. Here, the clinical evidence that delay in starting adjuvant chemotherapy beyond 61 days from surgery is detrimental,10 and that delaying radiotherapy (when chemotherapy is not given) by more than 6 weeks from surgery is associated with an increased risk of local recurrence,11 provides further support to meeting the guidelines.

The breast nurses and the newly appointed cancer care coordinators have been given the data collated for this review so they can work to streamline breast cancer patient pathways, both through the earlier diagnostic and surgical steps and onto adjuvant therapies.

This paper provides baseline data for breast cancer treatment indicators at Christchurch Public Hospital, showing areas of greatest delay to which interventions can be directed, and against which future performance can be compared. It also highlights the critical role of the regional breast cancer registers in auditing service delivery and the implementation of the Ministry of Health’s National Tumour Standards.

Summary

The care received by 288 breast cancer patients treated at Christchurch Hospital in 2012 was reviewed using the time points stipulated by the new Tumour Standards developed by Ministry of Health in 2013. Some of the Tumour Standards were achieved as the vast majority of patients received their first breast cancer treatment within 62 days of referral to the hospital (87%) and within 31 days of giving informed consent to the recommended treatment (89%). While only 64% of patients started chemotherapy within 42 days following their breast cancer surgery, 97% had commenced chemotherapy within 31 days of the decision for treatment. A number of interventions, such as improving the multidisciplinary meetings and the appointment of cancer nurse specialists to support patients during their treatment, have been implemented to resolve identified factors that delayed patient treatment times.

Abstract

Aim

To determine whether patients diagnosed with breast cancer in 2012 received timely access to services at Christchurch Hospital when audited against Ministry of Health Tumour Standards of Service Provision (TS) (2013) and the Faster Cancer Treatment (FCT) indicators, and to discover factors which impeded patient pathways, and which would need to be addressed in order to meet the standards.

Method

Data on referrals, dates and treatment for patients diagnosed with breast cancer at Christchurch Hospital was extracted from the Christchurch Breast Cancer Patient Register and other hospital databases.

Results

In 2012, 288 breast cancer patients were treated at Christchurch Hospital, 60% referred by general practitioners, and 40% via the national screening programme. Some 2013 Tumour Standards were achieved. The FCT indicator 1 (TS 2.4) and 3 (TS 2.5) were met, with 87% (≥80%) receiving their first treatment within 62 days of referral, and 89% (≥80%) within 31 days of decision-to-treat. However, FCT indicator 2 (TS 2.1), requiring first specialist assessment within 14 days of referral, was met in 61% (≥90% required). Only 64% of women started adjuvant chemotherapy within 42 days of their surgery (TS 2.6, ≥90%).

Conclusion

The management of breast cancer patients by a multidisciplinary team is crucial to ensure patients receive timely and appropriate care. However, waiting for weekly multidisciplinary meetings and adequate anatomical pathology resource, together with other factors, were identified as delaying the patient pathway and solutions to resolve these are discussed.

Author Information

Valerie C L Davey, Data Coordinator, Christchurch Breast Cancer Patient Register, Christchurch

Birgit Dijkstra, Consultant Breast & Endocrine Surgeon, Dept of Surgery, Christchurch Hospital, Christchurch

Gavin C Harris, Consultant Anatomical Pathologist, Canterbury Health Laboratories, Christchurch

Melissa L James, Radiation Oncologist, Oncology Service, Christchurch Hospital. Christchurch

Bridget A Robinson, Mackenzie Chair of Cancer Medicine, Dept of Medicine, University of Otago, Christchurch

Acknowledgements

The authors thank the following organisations and people:

  • New Zealand Breast Cancer Foundation (premier sponsor)
  • Canterbury District Health Board
  • Timi Boddington, Decision Support, Canterbury District Health Board
Alice Turner, Medical Student, University of Otago (Christchurch Campus)

Correspondence

Valerie Davey, Christchurch Breast Cancer Patient Register, c/o Dept of General Surgery, Christchurch Hospital, Private Bag 4710, Christchurch 8140, New Zealand. Fax: +64 (0)3 3640352

Correspondence Email

valerie.davey@cdhb.health.nz

Competing Interests

Nil.

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