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Summary for secondary care

Breast Cancer Quality Standard for Secondary Care

This specialist Guidelines summary covers quality standards for the management of early (ductal carcinoma in situ and invasive), locally advanced, and advanced breast cancer; recurrent breast cancer; and familial breast cancer in adults. This includes breast cancer identified through screening and by assessment of symptoms, and covers care from the point of referral to a specialist team. It does not cover adults with non-cancerous breast tumours.

This summary has been produced for use by oncology teams involved in the management of breast cancer. For information on rationales and quality measures, refer to the original quality standard (QS12) from NICE.

List of Quality Statements

Quality Statement 1: Timely Diagnosis

  • People with suspected breast cancer referred to specialist services are offered the triple diagnostic assessment in a single hospital visit
    • This consists of clinical assessment, mammography and/or ultrasound imaging, and fine needle aspiration or core biopsy
    • Healthcare professionals (such as doctors, nurses and specialists) ensure that people with suspected breast cancer referred to specialist services have the triple diagnostic assessment in a single hospital visit.

Quality Statement 2: Preoperative MRI Scan

  • People with biopsy-proven invasive breast cancer or ductal carcinoma in situ (DCIS) are not offered a preoperative MRI scan unless there are specific clinical indications for its use
    • Offer MRI of the breast to patients with invasive breast cancer:
      • if there is discrepancy regarding the extent of disease from clinical examination, mammography and ultrasound assessment for planning treatment
      • if breast density precludes accurate mammographic assessment
      • to assess the tumour size if breast conserving surgery is being considered for invasive lobular cancer.
See NICE's guideline on early and locally advanced breast cancer: diagnosis and management.

Quality Statement 3: Gene Expression Profiling

  • People with oestrogen receptor-positive (ER-positive), human epidermal growth factor receptor 2-negative (HER2-negative) and lymph node-negative early breast cancer who are at intermediate risk of distant recurrence are offered gene expression profiling
    • EndoPredict, Oncotype DX Breast Recurrence Score and Prosigna are recommended by NICE as options for guiding adjuvant chemotherapy decisions for people with ER-positive, HER2-negative and lymph node-negative early breast cancer who are assessed as being at intermediate risk of distant recurrence. (See NICE's diagnostic guidance on tumour profiling tests to guide adjuvant chemotherapy decisions in early breast cancer.)
    • A validated tool, such as PREDICT or the Nottingham Prognostic Index, must be used to determine if a person is at intermediate risk of distant recurrence. (See NICE's diagnostic guidance on tumour profiling tests to guide adjuvant chemotherapy decisions in early breast cancer.)

Quality Statement 4: ER and HER2 Receptor Status

  • People with newly diagnosed invasive breast cancer and those with recurrent breast cancer (if clinically appropriate) have the oestrogen receptor (ER) and human epidermal growth factor receptor 2 (HER2) status of the tumour assessed
    • Clinically appropriate is defined as where there is a recurrence of a breast tumour and it is suspected that the ER and HER2 status may be different to the original tumour and will lead to a change in management.

Quality Statement 5: Multidisciplinary Team Management of Metastatic Breast Cancer

  • People with breast cancer who develop metastatic disease have their treatment and care managed by a multidisciplinary team.

Quality Statement 6: Key Worker

  • People with locally advanced, metastatic or distant recurrent breast cancer are assigned a key worker.

Statements from the 2011 Quality Standard for Breast Cancer

Statements from the 2011 quality standard for breast cancer that are still supported by the evidence may still be useful at a local level.
  • People presenting with symptoms that suggest breast cancer are referred to a unit that performs diagnostic procedures in accordance with NHS Breast Screening Programme guidance
  • People with early invasive breast cancer are offered a pre-treatment ultrasound evaluation of the axilla and, if abnormal lymph nodes are identified, ultrasound-guided needle biopsy (fine needle aspiration or core). Those with no evidence of lymph node involvement on needle biopsy are offered sentinel lymph node biopsy when axillary surgery is performed
  • People with early breast cancer undergoing breast conserving surgery, which may include the use of oncoplastic techniques, have an operation that both minimises local recurrence and achieves a good aesthetic outcome
  • People with early breast cancer who are to undergo mastectomy have the options of immediate and planned delayed breast reconstruction discussed with them
  • People with early invasive breast cancer, irrespective of age, are offered surgery, radiotherapy and appropriate systemic therapy, unless significant comorbidity precludes it
  • People with early invasive breast cancer do not undergo staging investigations for distant metastatic disease in the absence of symptoms
  • People with early invasive breast cancer are involved in decisions about adjuvant therapy after surgery, which are based on an assessment of the prognostic and predictive factors, and the potential benefits and side effects
  • People having treatment for early breast cancer are offered personalised information and support, including a written follow-up care plan and details of how to contact a named healthcare professional
  • Women treated for early breast cancer have annual mammography for 5 years after treatment. After 5 years, women who are 50 or older receive breast screening according to the NHS Breast Screening Programme timescales, whereas women younger than 50 continue to have annual mammography until they enter the routine NHS Breast Screening Programme
  • People who have a single or small number of potentially resectable brain metastases, a good performance status and who have no (or minimal) other sites of metastatic disease are referred to a neuroscience brain and other rare CNS tumours multidisciplinary team.

References


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